What is the treatment for hospital-acquired pneumonia?

Treatment for Hospital-Acquired Pneumonia

The recommended treatment for hospital-acquired pneumonia (HAP) is prompt initiation of empiric broad-spectrum antibiotics based on risk factors for multidrug-resistant pathogens, with subsequent de-escalation based on culture results and clinical response. 1

Risk Assessment for Treatment Selection

Treatment selection should be guided by two key factors:

1. Risk for multidrug-resistant (MDR) pathogens
2. Risk of mortality

Low Risk Patients (Low MDR risk and mortality ≤15%)

For patients with low risk of MDR pathogens and low mortality risk, monotherapy is recommended with one of the following:

• Ertapenem 1 g IV daily (if Pseudomonas not suspected)
• Ceftriaxone 2 g IV daily
• Cefotaxime 2 g IV q8h
• Moxifloxacin 400 mg IV daily
• Levofloxacin 750 mg IV daily 2, 1

High Risk Patients (High MDR risk or mortality >15%)

Without Septic Shock

If a single broad-spectrum agent is active against >90% of likely Gram-negative pathogens in your ICU (based on local antibiogram), use one of:

• Piperacillin-tazobactam 4.5 g IV q6h
• Cefepime 2 g IV q8h
• Ceftazidime 2 g IV q8h
• Imipenem 500 mg IV q6h
• Meropenem 1 g IV q8h
• Levofloxacin 750 mg IV daily 2, 1

Add MRSA coverage if >25% of S. aureus respiratory isolates in your ICU are MRSA:

• Vancomycin 15-20 mg/kg IV q8-12h (target trough 15-20 μg/mL)
• Linezolid 600 mg IV q12h 2, 1

With Septic Shock

Use dual antipseudomonal coverage plus MRSA coverage if indicated:

1. Antipseudomonal β-lactam:

   • Piperacillin-tazobactam 4.5 g IV q6h
   • Cefepime 2 g IV q8h
   • Ceftazidime 2 g IV q8h
   • Imipenem 500 mg IV q6h
   • Meropenem 1 g IV q8h

2. PLUS second agent:

   • Ciprofloxacin 400 mg IV q8h
   • Levofloxacin 750 mg IV daily
   • Amikacin 15-20 mg/kg IV daily
   • Gentamicin 5-7 mg/kg IV daily
   • Tobramycin 5-7 mg/kg IV daily
   • Colistin (if high prevalence of MDR pathogens) 2, 1

3. PLUS MRSA coverage if indicated:

   • Vancomycin 15-20 mg/kg IV q8-12h
   • Linezolid 600 mg IV q12h 2, 1

Diagnostic Approach

• Obtain respiratory samples before initiating antibiotics
• Endotracheal aspirates with non-quantitative cultures are recommended as the initial diagnostic strategy
• Radiological confirmation with chest imaging is essential 1

De-escalation and Duration

• Reassess at 48-72 hours based on clinical response and culture results
• De-escalate to pathogen-specific therapy once culture results are available
• For confirmed MSSA, switch to oxacillin, nafcillin, or cefazolin
• Standard duration is 7-8 days for patients with good clinical response
• Consider longer durations for slow clinical response, highly resistant pathogens, structural lung disease, or complications 2, 1

Pathogen-Specific Considerations

Pseudomonas aeruginosa

For confirmed Pseudomonas pneumonia, combination therapy with an antipseudomonal β-lactam plus either an aminoglycoside or a fluoroquinolone is recommended to prevent resistance development 1

MRSA

For confirmed MRSA infection, targeted therapy with vancomycin or linezolid is recommended 2, 1

Acinetobacter species

For Acinetobacter not only sensitive to polymyxin:

• Ampicillin/sulbactam 3 g IV q6h
• Imipenem 500 mg IV q6h
• Meropenem 1 g IV q8h 2

Important Considerations

• Delaying empiric therapy is associated with increased mortality - initiate antibiotics promptly after obtaining cultures 1, 3
• Using inadequate empiric coverage, especially in high-risk patients, leads to poor outcomes - a study showed improved 14-day mortality (8% vs 23%) with guideline-based therapy 3
• Use local antibiograms to guide therapy - hospitals should generate and disseminate regular local antibiograms 1
• Consider PK/PD optimized dosing rather than standard manufacturer recommendations 1
• Adjust doses based on renal function 1
• The 2016 IDSA/ATS guidelines and 2017 ERS/ESICM/ESCMID/ALAT guidelines provide the most recent comprehensive recommendations for HAP treatment 2

Remember that appropriate initial antibiotic selection significantly impacts outcomes, with studies showing improved survival with guideline-concordant therapy 3. The goal is to provide effective coverage while minimizing unnecessary broad-spectrum antibiotic use that could promote resistance.