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

Treatment of Hospital-Acquired Pneumonia (HAP)

The recommended treatment for hospital-acquired pneumonia (HAP) should be based on risk stratification for mortality and MRSA, with empiric therapy tailored to these risk factors and local antibiogram data. 1, 2

Risk Stratification for HAP Treatment

Low Risk of Mortality and No MRSA Risk Factors

• Use one of the following as monotherapy:
  • Piperacillin-tazobactam 4.5 g IV q6h 1, 2
  • Cefepime 2 g IV q8h 1
  • Levofloxacin 750 mg IV daily 1, 2
  • Imipenem 500 mg IV q6h 1
  • Meropenem 1 g IV q8h 1

Low Risk of Mortality but with MRSA Risk Factors

• Use one antipseudomonal agent:
  • Piperacillin-tazobactam 4.5 g IV q6h 1, 2
  • Cefepime 2 g IV q8h 1
  • Levofloxacin 750 mg IV daily 1, 2
  • Imipenem 500 mg IV q6h 1
  • Meropenem 1 g IV q8h 1
• Plus MRSA coverage:
  • Vancomycin 15 mg/kg IV q8-12h (target trough 15-20 mg/mL) 1, 2
  • OR Linezolid 600 mg IV q12h 1, 2

High Risk of Mortality or Recent IV Antibiotics

• Use two antipseudomonal agents from different classes:
  • Piperacillin-tazobactam 4.5 g IV q6h 1, 2
  • Cefepime 2 g IV q8h 1
  • Levofloxacin 750 mg IV daily 1, 2
  • Imipenem 500 mg IV q6h 1
  • Meropenem 1 g IV q8h 1
  • Aminoglycoside (amikacin, gentamicin, or tobramycin) 1
  • Ciprofloxacin 400 mg IV q8h 1
  • Aztreonam 2 g IV q8h 1
• Plus MRSA coverage:
  • Vancomycin 15 mg/kg IV q8-12h (target trough 15-20 mg/mL) 1, 2
  • OR Linezolid 600 mg IV q12h 1, 2

Risk Factors to Consider

MRSA Risk Factors

• Prior intravenous antibiotic use within 90 days 1, 2
• Hospitalization in a unit where >20% of S. aureus isolates are methicillin-resistant 1, 2
• Unknown MRSA prevalence in the unit 2
• Prior detection of MRSA by culture 2

Mortality Risk Factors

• Need for ventilatory support due to HAP 1, 2
• Septic shock 1, 2

Special Considerations

• For patients with structural lung disease (bronchiectasis, cystic fibrosis), two antipseudomonal agents are recommended 1, 3
• For patients with gram stain showing numerous gram-negative bacilli, consider double coverage for gram-negative pathogens 2

Duration of Therapy

• A 7-day course of antimicrobial therapy is recommended for HAP 1
• Therapy may be shorter or longer depending on clinical, radiologic, and laboratory parameter improvements 1

Pathogen-Specific Considerations

Pseudomonas aeruginosa

• For definitive therapy, base treatment on antimicrobial susceptibility testing 1, 2
• For patients not in septic shock, monotherapy with an antibiotic to which the isolate is susceptible is recommended 1
• For patients in septic shock, combination therapy with two antibiotics to which the isolate is susceptible is suggested 1, 4
• Aminoglycoside monotherapy should never be used for P. aeruginosa HAP 1, 2

Acinetobacter Species

• For susceptible isolates, use a carbapenem or ampicillin/sulbactam 1
• For isolates sensitive only to polymyxins, use intravenous polymyxin (colistin or polymyxin B) with adjunctive inhaled colistin 1
• Avoid tigecycline for Acinetobacter HAP 1

ESBL-Producing Gram-Negative Bacilli

• Base therapy on antimicrobial susceptibility testing and patient-specific factors 1

Carbapenem-Resistant Pathogens

• For pathogens sensitive only to polymyxins, use intravenous polymyxins with adjunctive inhaled colistin 1

Important Caveats

• Empiric therapy should be based on local antibiogram data whenever possible 1, 2
• Early, appropriate antibiotic therapy is critical as delays increase mortality 5, 6
• De-escalate therapy once culture results are available 1
• Extended infusions may be appropriate for beta-lactams to optimize drug exposure 2
• Inappropriate or delayed therapy greatly increases morbidity and mortality 5, 6
• Nearly half of HAP cases are polymicrobial, which should be considered when selecting empiric therapy 4