From the Guidelines
The first-line treatment for hospital-acquired pneumonia (HAP) is empiric antibiotic therapy, which should be initiated promptly based on risk factors for specific pathogens and local patterns of antibiotic resistance.
Key Considerations
- The selection of initial antibiotic therapy is based on risk factors for specific pathogens, modified by knowledge of local patterns of antibiotic resistance and organism prevalence 1.
- Patients with late-onset HAP or risk factors for multidrug-resistant (MDR) pathogens require broad-spectrum therapy, which may include:
- Antipseudomonal cephalosporins (e.g., cefepime 1-2 g every 8-12 h)
- Carbapenems (e.g., imipenem 500 mg every 6 h or 1 g every 8 h)
- β-Lactam/β-lactamase inhibitors (e.g., piperacillin-tazobactam 4.5 g every 6 h)
- Aminoglycosides (e.g., gentamicin 7 mg/kg per day)
- Antipseudomonal fluoroquinolones (e.g., levofloxacin 750 mg every day)
- Vancomycin (15 mg/kg every 12 h) for patients with risk factors for MRSA 1.
Important Principles
- Avoid untreated or inadequately treated HAP, as delay in initiation of appropriate antibiotic therapy is associated with increased mortality 1.
- Recognize the variability of bacteriology from one hospital to another and from one time period to another, and use this information to alter the selection of an appropriate antibiotic treatment regimen for any specific clinical setting 1.
- Avoid the overuse of antibiotics by focusing on accurate diagnosis, tailoring therapy to the results of lower respiratory tract cultures, and shortening duration of therapy to the minimal effective period 1.
- Apply prevention strategies aimed at modifiable risk factors 1.
From the Research
First-Line Treatment for Hospital-Acquired Pneumonia (HAP)
The first-line treatment for HAP is typically an empiric and targeted therapy, which requires an accurate assessment of the risk for multidrug-resistant bacteria 2. The therapeutic approach must be patient-oriented and institution-specific, taking into account the specific risk factors of each patient, such as previous antibiotic exposure, underlying diseases, length of hospital stay, and the local patterns of antimicrobial resistance 3.
Key Considerations
- The initial optimal empirical therapy should be guided by the patient's risk factors and the local epidemiology of antimicrobial resistance 3, 4.
- Broad-spectrum antimicrobials, such as piperacillin-tazobactam and co-amoxiclav, are commonly used as empirical treatment regimens 5.
- The use of broad-spectrum antimicrobials should be balanced with the risk of promoting antimicrobial resistance and the potential for de-escalation of therapy once culture data are available 2, 3.
Duration of Therapy
- The optimal duration of antibiotic therapy for HAP is uncertain, but courses longer than 1 week are rarely justified 3.
- A short, fixed course (7-8 days) of antibiotic therapy may be sufficient for patients with ventilator-associated pneumonia (VAP) not due to non-fermenting Gram-negative bacilli (NF-GNB) 6.
- However, for patients with VAP due to NF-GNB, a longer course of therapy may be necessary to reduce the risk of recurrence 6.