What is the treatment for Hospital-Acquired Pneumonia (HAP)?

Treatment for Hospital-Acquired Pneumonia (HAP)

For hospital-acquired pneumonia, empiric antibiotic therapy should be initiated promptly with broad-spectrum coverage for patients with risk factors for multidrug-resistant (MDR) pathogens, while patients without risk factors can receive more targeted therapy. 1

Initial Assessment and Risk Stratification

The key decision in initial empiric therapy is determining whether the patient has risk factors for MDR organisms:

Risk Factors for MDR Pathogens:

• Prior intravenous antibiotic use within 90 days
• Late-onset HAP (≥5 days after hospitalization)
• Septic shock
• Hospitalization in units with high rates of MDR pathogens
• Acute renal replacement therapy
• Structural lung disease
• Previous colonization with MDR pathogens 1

Empiric Antibiotic Therapy

For Patients WITHOUT Risk Factors for MDR Pathogens:

Monotherapy with one of the following:

• Piperacillin-tazobactam 4.5 g IV every 6 hours
• Cefepime 2 g IV every 8 hours
• Levofloxacin 750 mg IV daily
• Ertapenem 1 g IV daily (if Pseudomonas not suspected) 1

For Patients WITH Risk Factors for MDR Pathogens:

Combination therapy with:

1. An anti-pseudomonal β-lactam:
   • Piperacillin-tazobactam 4.5 g IV every 6 hours
   • Cefepime 1-2 g IV every 8 hours
   • Ceftazidime 2 g IV every 8 hours
   • Imipenem 500 mg IV every 6 hours or 1 g every 8 hours
   • Meropenem 1 g IV every 8 hours 2, 1

PLUS

1. Either an aminoglycoside:
   • Amikacin 15-20 mg/kg IV daily
   • Gentamicin 5-7 mg/kg IV daily
   • Tobramycin 5-7 mg/kg IV daily 2, 1

OR

1. An antipseudomonal fluoroquinolone:
   • Ciprofloxacin 400 mg IV every 8 hours
   • Levofloxacin 750 mg IV daily 2, 1

MRSA Coverage:

Add MRSA coverage if risk factors are present or if >25% of S. aureus respiratory isolates in the ICU are MRSA:

• Vancomycin 15-20 mg/kg IV every 8-12 hours (target trough 15-20 μg/mL)
• Linezolid 600 mg IV every 12 hours 2, 1

Special Considerations

For Pseudomonas aeruginosa:

• For confirmed Pseudomonas pneumonia, combination therapy with an antipseudomonal β-lactam plus either an aminoglycoside or a fluoroquinolone is recommended 1
• For nosocomial pneumonia caused by P. aeruginosa, piperacillin-tazobactam should be used in combination with an aminoglycoside 3

For Staphylococcus aureus:

• For confirmed MRSA: Continue vancomycin or linezolid
• For confirmed MSSA: De-escalate to oxacillin, nafcillin, or cefazolin 1

Duration of Therapy and De-escalation

• Standard duration: 7-8 days for patients with good clinical response 1

• Consider longer durations (10-14 days) for:

  • Slow clinical response
  • Highly resistant pathogens
  • Structural lung disease
  • Complications 1

• Reassess at 48-72 hours based on clinical response and culture results 1

• De-escalate therapy once culture results are available to target the specific pathogens identified 1

Important Caveats

• Delays in appropriate antibiotic therapy increase mortality; therefore, do not delay treatment to obtain cultures in critically ill patients 2, 1
• Lower respiratory tract cultures should be collected from all patients before antibiotic therapy when possible 2
• Use local antibiograms to guide empiric therapy choices, as pathogen prevalence and resistance patterns vary between hospitals 1
• Adjust antibiotic doses based on renal function; for patients with renal impairment (creatinine clearance ≤40 mL/min), reduce doses of piperacillin-tazobactam and other renally cleared antibiotics 3
• Negative lower respiratory tract cultures can be used to stop antibiotic therapy if obtained before antibiotic changes in the previous 72 hours 2