What are the antibiotic guidelines for Hospital-Acquired Pneumonia (HAP)?

From the Guidelines

Hospital-acquired pneumonia should be treated with empiric broad-spectrum antibiotics that cover both gram-negative bacteria and methicillin-resistant Staphylococcus aureus (MRSA), with the specific regimen chosen based on the patient's risk of mortality and likelihood of MRSA, 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, treatment options include piperacillin-tazobactam 4.5 g IV every 6 hours, cefepime 2 g IV every 8 hours, levofloxacin 750 mg IV daily, imipenem 500 mg IV every 6 hours, or meropenem 1 g IV every 8 hours 1. Some key points to consider when selecting an empiric antibiotic regimen for HAP include:

• The need for coverage of MRSA, which can be achieved with vancomycin 15 mg/kg IV every 8-12 hours or linezolid 600 mg IV every 12 hours 1
• The importance of considering local antibiogram data when selecting specific agents 1
• The potential need for additional coverage for multidrug-resistant organisms, such as with an aminoglycoside like amikacin 15-20 mg/kg IV daily or a fluoroquinolone like ciprofloxacin 400 mg IV every 8 hours 1
• The recommendation to obtain respiratory cultures before starting antibiotics when possible, and to de-escalate therapy once culture results are available 1
• The typical treatment duration of 7 days, which may be extended based on clinical response 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.

The recommended antibiotic guide for hospital-acquired pneumonia using piperacillin-tazobactam (IV) is as follows:

• Indication: 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.
• Dosage: 4.5 grams every six hours plus an aminoglycoside, totaling 18.0 grams (16.0 grams piperacillin and 2.0 grams tazobactam).
• Administration: Administer by intravenous infusion over 30 minutes.
• Duration: The recommended duration of piperacillin and tazobactam for injection treatment for nosocomial pneumonia is 7 to 14 days 2.

From the Research

Hospital Acquired Pneumonia Antibiotic Guide

Overview of Antibiotic Treatment

• Hospital-acquired pneumonia (HAP) is a form of nosocomial pneumonia that requires different treatment approaches compared to ventilator-associated pneumonia (VAP) 3.
• The choice of antibiotic treatment for HAP depends on various factors, including the risk of multidrug-resistant (MDR) organisms and the patient's individual risk factors 4, 5.

Recommended Antibiotics

• Piperacillin-tazobactam is recommended as an empiric treatment for HAP, especially in patients with early onset, non-ventilator HAP (NV-HAP) 4, 5.
• Other recommended antibiotics for HAP include cefepime, carbapenems, and fluoroquinolones 5.
• For patients at risk of MDR organism infection, broader-spectrum empiric antibiotic therapies that target P. aeruginosa and methicillin-resistant S. aureus are recommended 5.

Antibiotic Resistance and Treatment

• The increasing prevalence of MDR organisms worldwide requires the use of broad-spectrum antibiotics in the treatment of HAP 4, 5.
• The use of an ICU and culture-type specific antibiogram can help determine the optimal initial antibiotic regimen for HAP 6.
• The emergence of MDR organisms as causal agents of HAP makes it necessary to accurately assess risk factors and revise knowledge on specific antimicrobial susceptibility patterns from each institution 5.

Treatment Considerations

• The appropriateness of the initial antibiotic regimen is a vital determinant of outcome in HAP patients 7.
• Continuous evaluation of antimicrobial therapeutic options, along with their pharmacodynamic and pharmacokinetic profiles, is mandatory to optimize therapy and reduce HAP-related mortality 7.
• Specific drug pharmacokinetic and pharmacodynamic considerations are necessary in elderly patients with HAP 5.