From the Guidelines
Hospital-acquired pneumonia (HAP) should be treated with empiric antibiotic therapy based on the patient's risk for multidrug-resistant (MDR) pathogens and mortality, with options including antibiotic monotherapy for low-risk patients and dual Gram-negative coverage with MRSA therapy for high-risk patients. The treatment approach for HAP is guided by the patient's risk factors, including the presence of septic shock, mortality risk, and the prevalence of MDR pathogens in the intensive care unit (ICU) 1.
Key Considerations
- For patients with low MDR pathogen risk and low mortality risk, antibiotic monotherapy with ertapenem, ceftriaxone, cefotaxime, moxifloxacin, or levofloxacin is recommended 1.
- High-risk patients, defined as those with a high risk for MDR pathogens or a mortality risk greater than 15%, require broader coverage, which may include a single broad-spectrum agent active against >90% of Gram-negative pathogens or dual Gram-negative coverage with MRSA therapy 1.
- The choice of empiric therapy should be guided by local antibiograms and the prevalence of specific pathogens in the ICU, including MRSA, Pseudomonas, and Acinetobacter 1.
Treatment Options
- For high-risk patients not in septic shock, a single agent such as imipenem, meropenem, cefepime, piperacillin/tazobactam, levofloxacin, or ceftazidime may be used, with the addition of MRSA coverage if necessary 1.
- For high-risk patients in septic shock, dual Gram-negative coverage with MRSA therapy is recommended, which may include an antipseudomonal β-lactam plus an aminoglycoside or an antipseudomonal quinolone 1.
Duration of Treatment
- The duration of treatment for HAP is typically 7 days, but may be adjusted based on clinical response and culture results 1.
Prevention Strategies
- Prevention of HAP is crucial and includes strict hand hygiene, early mobilization, elevation of the head of the bed, oral care with chlorhexidine, and minimizing sedation for ventilated patients 1.
From the FDA Drug Label
Piperacillin and Tazobactam for Injection is indicated in adults and pediatric patients (2 months of age and older) for the treatment of nosocomial pneumonia (moderate to severe) caused by beta-lactamase producing isolates of Staphylococcus aureus and by piperacillin and tazobactam-susceptible Acinetobacter baumannii, Haemophilus influenzae, Klebsiella pneumoniae, and Pseudomonas aeruginosa (Nosocomial pneumonia caused by P. aeruginosa should be treated in combination with an aminoglycoside) Initial presumptive treatment of adult patients with nosocomial pneumonia should start with piperacillin and tazobactam for injection at a dosage of 4.5 grams every six hours plus an aminoglycoside, [totaling 18.0 grams (16.0 grams piperacillin and 2.0 grams tazobactam)], administered by intravenous infusion over 30 minutes.
Hospital-acquired pneumonia is treated with piperacillin-tazobactam (IV) at a dosage of 4.5 grams every six hours plus an aminoglycoside. The recommended duration of treatment is 7 to 14 days 2.
- Key points:
- Piperacillin-tazobactam (IV) is indicated for the treatment of nosocomial pneumonia.
- The dosage for adult patients with nosocomial pneumonia is 4.5 grams every six hours plus an aminoglycoside.
- Treatment should be administered by intravenous infusion over 30 minutes.
- The recommended duration of treatment is 7 to 14 days.
From the Research
Hospital Acquired Pneumonia
- Hospital-acquired pneumonia (HAP) is associated with high morbidity and mortality, and early, appropriate, and adequate empiric therapy can increase the chance of survival 3.
- The American Thoracic Society provided guidelines for the initial treatment of immunocompetent HAP patients in 1995, but these guidelines have several important limitations, including a lack of recommendations for duration of therapy and no recognition of newer drugs 3.
- Broad-spectrum antibiotics are recommended in the treatment of HAP, but it remains controversial whether patients with early onset, non-ventilator HAP (NV-HAP) should also be empirically treated with broad-spectrum antibiotics 4.
- A study compared the clinical benefit of ceftriaxone plus clindamycin vs piperacillin/tazobactam as the initial empirical treatment of adults with early NV-HAP, and found that treatment with piperacillin/tazobactam was more effective than that with ceftriaxone plus clindamycin in patients with early NV-HAP 4.
- Another study compared the clinical outcomes of patients with HAP who were treated with cefepime and those treated with piperacillin/tazobactam, and found that treatment outcomes, including rates of in-hospital mortality, pneumonia-related readmission, and all-cause mortality within 6 months after discharge, were comparable between the two groups 5.
Diagnosis and Management
- HAP and ventilator-associated pneumonia (VAP) are especially challenging to diagnose promptly in the intensive care unit because a plethora of other causes can contribute to clinical decline in complex, critically ill patients 6.
- A locally-derived empiric algorithm supported by local microbiologic data can predict more accurate coverage than one defined strictly by an unmodified guideline-driven approach 7.
- Understanding local patterns of pneumonia ensures the creation and maintenance of empiric algorithms that achieve the best clinical outcomes 7.
- Effective computerized antibiotic management programs that incorporate information on local patterns of antimicrobial resistance can assist physicians in empiric therapy decision making, improve patient quality of care, and reduce medical costs 3.
Prevention
- Prevention of HAP and VAP is crucial to reduce inpatient morbidity and mortality 6.
- Strategies for prevention include tube feeding, suctioning, positioning care, and intensive care unit admission 5.
- A study found that among patients who were at risk for aspiration, such as those receiving tube feeding, those who received piperacillin/tazobactam had lower rates of in-hospital mortality 5.