What is the recommended management for hospital-acquired pneumonia (HAP)?

Management of Hospital-Acquired Pneumonia (HAP)

The recommended management for hospital-acquired pneumonia requires risk stratification for multidrug-resistant pathogens, obtaining respiratory cultures before antibiotics, initiating appropriate empiric therapy based on risk factors, and de-escalating treatment based on culture results. 1, 2

Diagnosis and Initial Assessment

• HAP is defined as pneumonia occurring ≥48 hours after hospitalization in non-intubated patients 2
• Obtain lower respiratory tract samples (distal quantitative or proximal quantitative/qualitative cultures) before starting antibiotics to guide targeted therapy 1
• Distal quantitative samples are preferred in stable patients with suspected VAP to reduce unnecessary antibiotic exposure and improve diagnostic accuracy 1
• Respiratory samples should be collected noninvasively before initiating antibiotics to guide targeted therapy and subsequent de-escalation 2

Risk Stratification for Empiric Therapy

Low Risk for MDR Pathogens:

• Early-onset HAP (within first 4-5 days of hospitalization)
• No prior antibiotic use
• No septic shock
• No risk factors for MDR pathogens
• Hospital unit with low prevalence of resistant pathogens (<25%) 1, 2

High Risk for MDR Pathogens:

• Late-onset HAP (>5 days of hospitalization)
• Prior intravenous antibiotic use within 90 days
• Septic shock or need for ventilatory support
• Previous colonization with MDR pathogens
• Hospital unit with high prevalence of resistant pathogens (>25%) 1, 2

Empiric Antibiotic Recommendations

For Low-Risk HAP:

• Use narrow-spectrum antibiotics such as:
  • Ertapenem
  • Ceftriaxone
  • Cefotaxime
  • Moxifloxacin
  • Levofloxacin 1, 2, 3
• Consider risk of Clostridium difficile with third-generation cephalosporins compared to penicillins or quinolones 1

For High-Risk HAP:

• Initiate broad-spectrum empiric therapy targeting:
  • Pseudomonas aeruginosa
  • Extended-spectrum β-lactamase (ESBL)-producing organisms
  • MRSA (if risk factors present) 1, 2
• Recommended regimens include:
  • Piperacillin-tazobactam (4.5g every 6 hours) 4
  • Cefepime
  • Meropenem or imipenem
  • Plus vancomycin or linezolid (if MRSA risk) 1, 2, 3
• For high-risk patients, especially those in septic shock, initial empiric combination therapy is recommended to cover Gram-negative bacteria 1

Duration of Therapy and De-escalation

• Tailor antibiotic therapy based on culture results and clinical response by day 3 (good practice statement) 1, 2
• For uncomplicated HAP with good clinical response, a 7-8 day course of antibiotics is recommended 1
• Longer courses may be needed for:
  • Immunodeficiency
  • Cystic fibrosis
  • Empyema
  • Lung abscess
  • Necrotizing pneumonia
  • Infection with non-fermenting gram-negative bacilli 1
• If cultures are negative and clinical improvement is observed, consider stopping antibiotics, especially if samples were obtained before antibiotic changes in the past 72 hours 1

Special Considerations

• For Pseudomonas aeruginosa infections:

  • Avoid aminoglycoside monotherapy (strong recommendation) 1
  • For definitive therapy, use monotherapy with an agent to which the isolate is susceptible 1
  • Consider combination therapy for patients who remain in septic shock or at high risk of death 1

• For Acinetobacter species:

  • Consider carbapenem or ampicillin/sulbactam if susceptible 1
  • For colistin-only sensitive strains, use intravenous polymyxin (colistin or polymyxin B) with adjunctive inhaled colistin 1
  • Avoid tigecycline for HAP caused by Acinetobacter species 1, 5

Common Pitfalls to Avoid

• Using aminoglycosides as monotherapy for HAP (never recommended) 1, 2
• Continuing unnecessarily broad therapy after culture results are available 2, 3
• Failing to adjust therapy based on patient-specific risk factors for MDR pathogens 2, 3
• Treating suspected HAP without obtaining respiratory cultures 1
• Not considering local antibiogram data when selecting empiric therapy 1, 2
• Delaying appropriate broad-spectrum therapy in high-risk patients, which can increase mortality 1, 6