From the Guidelines
The antibiotics of choice for Hospital-Acquired Pneumonia (HAP) are piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem, with vancomycin or linezolid added for MRSA coverage in high-risk patients.
Antibiotic Selection
The selection of antibiotics for HAP depends on the patient's risk of mortality and the likelihood of methicillin-resistant Staphylococcus aureus (MRSA) infection 1.
- For patients not at high risk of mortality and without factors increasing the likelihood of MRSA, monotherapy with 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 is recommended 1.
- For patients at high risk of mortality or with factors increasing the likelihood of MRSA, combination therapy with two of the following antibiotics is recommended: piperacillin-tazobactam 4.5 g IV q6h, cefepime or ceftazidime 2 g IV q8h, levofloxacin 750 mg IV daily, ciprofloxacin 400 mg IV q8h, imipenem 500 mg IV q6h, meropenem 1 g IV q8h, amikacin 15–20 mg/kg IV daily, gentamicin 5–7 mg/kg IV daily, or tobramycin 5–7 mg/kg IV daily 1.
MRSA Coverage
For patients with a high risk of MRSA infection, vancomycin 15 mg/kg IV q8–12h or linezolid 600 mg IV q12h should be added to the antibiotic regimen 1.
Key Considerations
- The choice of antibiotics should be guided by local antibiograms and the patient's individual risk factors 1.
- Aminoglycosides should not be used as the sole antipseudomonal agent 1.
- For patients with structural lung disease or a high risk of gram-negative infection, two antipseudomonal agents may be recommended 1.
From the Research
Antibiotics of Choice for Hospital-Acquired Pneumonia (HAP)
The choice of antibiotics for HAP depends on various factors, including the severity of the infection, the presence of multidrug-resistant organisms, and local patterns of infection.
- The antibiotics that are commonly prescribed for HAP include carbapenems, piperacillin/tazobactam, and quinolones 2.
- Empiric anti-pseudomonal antibiotics and empiric anti-MRSA antibiotics are independent predictors of appropriate therapy for HCAP 3.
- Cefiderocol, a novel siderophore cephalosporin, has shown efficacy in treating infections caused by multidrug-resistant gram-negative pathogens, including Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter baumannii 4.
Duration of Antibiotic Therapy
The optimal duration of antibiotic therapy for HAP is uncertain, but studies suggest that a short course of antibiotics (7-8 days) may be as effective as a prolonged course (10-15 days) in patients with VAP not due to non-fermenting Gram-negative bacilli (NF-GNB) 5, 6.
- A short course of antibiotics may reduce the emergence of resistant organisms and decrease the risk of superinfection or emergence of antimicrobial resistance 5, 6.
- However, for patients with VAP due to NF-GNB, a prolonged course of antibiotics may be necessary to prevent recurrence 5, 6.
Factors Influencing Antibiotic Choice
The choice of antibiotics for HAP is influenced by various factors, including:
- Admission category: trauma patients are more likely to be prescribed non-anti-Pseudomonas cephalosporins, while surgical patients are less likely to receive aminoglycosides 2.
- Sickness severity: patients with higher sickness severity scores are more likely to receive carbapenems 2.
- Local patterns of infection: the prevalence of Acinetobacter species >10% in pneumonia episodes increases the prescription of carbapenems and colistin 2.