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

Treatment of Hospital-Acquired Pneumonia

For hospital-acquired pneumonia (HAP), empiric antibiotic therapy should be based on risk assessment for multidrug-resistant (MDR) pathogens, with broad-spectrum coverage for high-risk patients and more targeted therapy for low-risk patients. 1

Risk Assessment for MDR Pathogens

• Low risk for MDR pathogens: Early-onset HAP (within first 4-5 days of hospitalization) with no other risk factors for resistant organisms and stable hemodynamics 1

• High risk for MDR pathogens: 1

  • Late-onset HAP (>5 days of hospitalization)
  • Prior antibiotic use within 90 days
  • High local prevalence of resistant pathogens (>25% in the ICU)
  • Septic shock or high risk of mortality
  • Prolonged hospitalization
  • Previous colonization with MDR pathogens

Empiric Antibiotic Therapy

Low-Risk Patients (early-onset, no MDR risk factors, stable)

• Recommended monotherapy options: 1
  • Ertapenem
  • Ceftriaxone or cefotaxime
  • Moxifloxacin or levofloxacin 750 mg IV daily

High-Risk Patients (late-onset or MDR risk factors)

• Without septic shock: 1

  • Single antipseudomonal agent if local susceptibility patterns show >90% coverage:
    • Piperacillin-tazobactam 4.5g IV q6h 2
    • Cefepime 2g IV q8h
    • Ceftazidime 2g IV q8h
    • Imipenem 500mg IV q6h
    • Meropenem 1g IV q8h
    • Levofloxacin 750mg IV daily 3

• With septic shock or unstable hemodynamics: 1

  • Combination therapy with two antipseudomonal agents:
    • Antipseudomonal β-lactam (piperacillin-tazobactam, cefepime, ceftazidime, imipenem, or meropenem)
    • PLUS either:
      • Aminoglycoside (gentamicin 5-7 mg/kg IV daily or amikacin 15-20 mg/kg IV daily) or
      • Antipseudomonal fluoroquinolone (ciprofloxacin 400mg IV q8h or levofloxacin 750mg IV daily)

• Add MRSA coverage if prevalence of MRSA among S. aureus isolates in your unit is >25% or unknown: 1

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

Diagnostic Approach

• Obtain lower respiratory tract cultures before starting antibiotics but do not delay therapy in critically ill patients 1

• Acceptable sampling methods: 1

  • Distal quantitative samples (preferred in stable patients)
  • Proximal quantitative samples
  • Qualitative cultures

De-escalation and Duration of Therapy

• De-escalate therapy based on culture results and clinical response at day 3 1

• Duration of therapy: 1

  • 7-8 days for patients with good clinical response
  • Longer course (14 days) may be needed for:
    • Immunocompromised patients
    • Infections with non-fermenting Gram-negative bacilli (especially P. aeruginosa)
    • Empyema, lung abscess, necrotizing pneumonia

Common Pathogens in HAP

• Early-onset HAP: Methicillin-sensitive S. aureus, Streptococcus pneumoniae, Haemophilus influenzae, and antibiotic-sensitive Enterobacteriaceae 1, 4

• Late-onset HAP or with risk factors for MDR: 1, 4, 5

  • Pseudomonas aeruginosa
  • Acinetobacter species
  • MRSA
  • Extended-spectrum β-lactamase (ESBL) producing organisms
  • Klebsiella pneumoniae
  • Other resistant Gram-negative bacilli

Important Caveats

• Local antibiograms should guide therapy - resistance patterns vary significantly between hospitals and units 1

• Inappropriate initial therapy increases mortality - ensure adequate empiric coverage for likely pathogens 1, 6

• Overdiagnosis is common - only 65% of clinically suspected HAP cases have radiological confirmation 5

• Consider combination therapy for P. aeruginosa infections to prevent emergence of resistance, especially in critically ill patients 4, 6

• Healthcare-associated pneumonia (HCAP) should be treated similarly to HAP, as patients often have similar risk factors for MDR pathogens 1