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

From the Guidelines

Hospital-acquired pneumonia (HAP) should be treated with empiric broad-spectrum antibiotics, with the initial treatment often including combination therapy with an antipseudomonal beta-lactam plus either a fluoroquinolone or an aminoglycoside, and adding vancomycin or linezolid for patients at risk for methicillin-resistant Staphylococcus aureus (MRSA) 1.

Treatment Approach

The treatment approach for HAP depends on the risk of mortality and the likelihood of multidrug-resistant (MDR) pathogens.

• For patients not at high risk of mortality and without factors increasing the likelihood of MDR pathogens, treatment options include piperacillin-tazobactam 4.5g IV every 6 hours, cefepime 2g IV every 8 hours, levofloxacin 750mg IV daily, imipenem 500mg IV every 6 hours, or meropenem 1g IV every 8 hours 2.
• For patients at high risk of mortality or with factors increasing the likelihood of MDR pathogens, treatment should include a combination of antibiotics, such as an antipseudomonal beta-lactam (e.g., piperacillin-tazobactam, cefepime, or meropenem) plus an aminoglycoside (e.g., amikacin) or a fluoroquinolone (e.g., levofloxacin), and adding vancomycin or linezolid for MRSA coverage 1.

Antibiotic Selection

The selection of antibiotics should be based on local antibiograms and the patient's individual risk factors.

• For patients with severe penicillin allergy, aztreonam can be used as an alternative to beta-lactam antibiotics, but should be combined with an agent that provides coverage for methicillin-susceptible Staphylococcus aureus (MSSA) 2.
• For patients at risk for MRSA, vancomycin or linezolid should be added to the initial empiric therapy 1.

Treatment Duration and De-escalation

The treatment duration for HAP is typically 7 days, but may be extended for complicated cases or certain pathogens.

• Antibiotic therapy should be de-escalated based on culture results and clinical response, usually within 48-72 hours 1.

Supportive Care

Supportive care, including oxygen therapy, proper positioning, and respiratory physiotherapy, is also essential for the management of HAP.

• Regular reassessment of the patient's clinical status is crucial to determine treatment effectiveness and the need for any adjustments 1.

From the FDA Drug Label

The cure rates in clinically evaluable patients with nosocomial pneumonia were 57% for linezolid-treated patients and 60% for vancomycin-treated patients. The cure rates in clinically evaluable patients with ventilator-associated pneumonia were 47% for linezolid-treated patients and 40% for vancomycin-treated patients. The pooled clinical cure rates for patients with HAP due to MDRSP were 12/18 (67%) in the MITT and 10/12 (83%) in the ME populations respectively.

The treatment of hospital-acquired pneumonia (HAP) includes linezolid and vancomycin.

• Linezolid has a cure rate of 57% in clinically evaluable patients and 67% in patients with HAP due to multi-drug resistant Streptococcus pneumoniae (MDRSP).
• Vancomycin has a cure rate of 60% in clinically evaluable patients. 3

From the Research

Treatment of Hospital Acquired Pneumonia

• The treatment of hospital-acquired pneumonia (HAP) is challenging due to increasing antibiotic resistance among common bacterial pathogens, especially Enterobacterales and nonfermenting gram-negative bacteria 4.
• New antibiotics, such as ceftobiprole, ceftolozane-tazobactam, ceftazidime-avibactam, meropenem-vaborbactam, imipenem-relebactam, and cefiderocol, have been approved or are in development for the treatment of HAP and ventilator-associated pneumonia (VAP) 4.
• The choice of empiric treatment for HAP and VAP is crucial, as failure to cover the causative agents has been associated with worse clinical outcomes 4.
• Aerosolized antibiotics are being increasingly used to treat respiratory infections, including HAP and VAP, especially in patients with multidrug-resistant pathogens 5.
• However, the use of aerosolized antibiotics is limited by insufficient efficacy and potential side effects, and high-quality evidence is lacking 5.

Comparison with Ventilator-Associated Pneumonia

• HAP and VAP have different natural histories, risk factors, and bacteriology, necessitating a different approach to therapy 6.
• The American and European nosocomial pneumonia guidelines make different therapy recommendations for HAP, with the American guidelines recommending broader spectrum therapy 6.
• However, recent studies suggest that not all HAP patients need antipseudomonal therapy, and an algorithm-based approach can provide appropriate therapy without overusing broad-spectrum therapy 6.

Other Considerations

• Macrolide resistance is common in Streptococcus pneumoniae community-acquired pneumonia, but azithromycin remains protective despite macrolide resistance 7.
• The use of azithromycin is associated with a reduction in in-hospital mortality, independent of multiple co-variates, in patients with Streptococcus pneumoniae community-acquired pneumonia in the intensive care unit 7.