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

From the Guidelines

Hospital-acquired pneumonia (HAP) treatment should be initiated with empiric broad-spectrum antibiotics, with the specific regimen chosen based on the patient's risk of mortality and likelihood of methicillin-resistant Staphylococcus aureus (MRSA) infection, as outlined in the 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society 1. For patients not at high risk of mortality and without factors increasing the likelihood of MRSA, recommended initial empiric antibiotic therapy includes piperacillin-tazobactam 4.5 g IV q6h, cefepime 2 g IV q8h, levofloxacin 750 mg IV daily, imipenem 500 mg IV q6h, or meropenem 1 g IV q8h. Some key points to consider when selecting an empiric regimen include:

• Coverage for MRSA with vancomycin 15 mg/kg IV q8-12h or linezolid 600 mg IV q12h if necessary
• Avoidance of using two β-lactams in combination
• Consideration of the patient's prior antibiotic use and local antimicrobial resistance patterns
• The importance of obtaining respiratory cultures before starting antibiotics when possible
• The need for clinical reassessment at 48-72 hours to consider de-escalation based on culture results, with a typical treatment duration of 7 days for most patients. In patients at high risk of mortality or with recent intravenous antibiotic use, a combination of two antibiotics, such as piperacillin-tazobactam and an aminoglycoside, may be necessary, with careful consideration of potential toxicities and resistance patterns 1.

From the FDA Drug Label

1. 2 Nosocomial Pneumonia 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) [see Dosage and Administration (2)].

Hospital-Acquired Pneumonia (HAP) Treatment: Piperacillin and Tazobactam for Injection is indicated for the treatment of nosocomial pneumonia, including HAP, in adults and pediatric patients (2 months of age and older) caused by certain bacteria, including Staphylococcus aureus, Acinetobacter baumannii, Haemophilus influenzae, Klebsiella pneumoniae, and Pseudomonas aeruginosa. The recommended dosage for HAP is 4.5 grams every six hours plus an aminoglycoside, totaling 18.0 grams (16.0 grams piperacillin and 2.0 grams tazobactam) 2.

From the Research

Hospital-Acquired Pneumonia (HAP) Treatment

• HAP is a form of nosocomial pneumonia that can arise both in and out of the ICU, and can lead to severe illness, including the need for intubation and mechanical ventilation 3.
• The treatment of HAP is challenging due to the increasing prevalence of multidrug-resistant organisms, and the need for broad-spectrum antibiotics 4, 5.
• The choice of empirical antibiotic therapy for HAP is crucial, and should be based on the patient's risk factors, such as the presence of multidrug-resistant pathogens, and the local epidemiology of the hospital 3, 5.

Comparison of Antibiotic Treatments

• A study comparing ceftriaxone plus clindamycin with piperacillin/tazobactam as initial empirical treatment for early non-ventilator HAP found that piperacillin/tazobactam was more effective in reducing clinical failure 4.
• Another study comparing cefepime with piperacillin/tazobactam treatment in patients with HAP found that treatment outcomes, including in-hospital mortality and pneumonia-related readmission, were comparable between the two groups 6.
• However, in a subgroup analysis of patients who required tube feeding, the risk of in-hospital mortality was significantly higher among those who received cefepime 6.

Risk Factors and Algorithms for Empirical Treatment

• The American and European nosocomial pneumonia guidelines propose different risk factors and treatment approaches for HAP, with the American guidelines recommending broader spectrum therapy 3.
• A study proposed an algorithm for the empirical treatment of HAP, which necessitates dual antipseudomonal therapy in less than 25% of all HAP patients 3.
• The guidelines emphasize the importance of knowing the local causative organisms and their resistance profiles in order to select the most appropriate empirical antibiotic therapy 7.