From the Guidelines
For nursing home patients with pneumonia requiring inpatient treatment, I recommend empiric coverage with piperacillin-tazobactam 4.5 g IV q6h or levofloxacin 750 mg IV daily, considering the patient's risk factors for multidrug-resistant organisms, such as MRSA and Pseudomonas. When determining the appropriate antibiotic regimen, it is essential to consider the patient's risk factors, including prior antibiotic use, healthcare exposures, and communal living conditions, which increase the likelihood of multidrug-resistant organisms, such as MRSA and Pseudomonas 1. The choice of antibiotic should be based on the patient's risk of mortality and factors that increase the likelihood of MRSA, with options including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, and meropenem, as outlined in the 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society 1. Some key considerations for antibiotic selection include:
- Piperacillin-tazobactam 4.5 g IV q6h for patients at high risk of mortality or with prior intravenous antibiotic use
- Levofloxacin 750 mg IV daily for patients with factors increasing the likelihood of MRSA
- Vancomycin 15 mg/kg IV q8-12h for MRSA coverage, with a goal to target 15-20 mg/mL trough level
- Aztreonam 2 g IV q8h for patients with severe penicillin allergy, with additional coverage for MSSA. It is crucial to start antibiotic therapy promptly, obtain appropriate cultures, and transition to oral antibiotics when the patient shows clinical improvement, to minimize the risk of antibiotic resistance and optimize patient outcomes 1.
From the FDA Drug Label
Adult Patients with Nosocomial Pneumonia: Initial presumptive treatment of 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). Levofloxacin tablets are indicated for the treatment of nosocomial pneumonia due to methicillin-susceptible Staphylococcus aureus, Pseudomonas aeruginosa, Serratia marcescens, Escherichia coli, Klebsiella pneumoniae, Haemophilus influenzae, or Streptococcus pneumoniae.
The patient coming from a nursing home with pneumonia should be treated with piperacillin-tazobactam plus an aminoglycoside or levofloxacin as the inpatient antibiotics, considering the causative pathogens of nosocomial pneumonia.
- Piperacillin-tazobactam is recommended for nosocomial pneumonia at a dosage of 4.5 grams every six hours plus an aminoglycoside 2.
- Levofloxacin is indicated for the treatment of nosocomial pneumonia due to specific microorganisms, including methicillin-susceptible Staphylococcus aureus, Pseudomonas aeruginosa, and others 3.
From the Research
Inpatient Antibiotics for Pneumonia Patients from Nursing Homes
- The choice of inpatient antibiotics for pneumonia patients from nursing homes depends on various factors, including the severity of the infection and the presence of risk factors for aspiration pneumonia 4.
- Tazobactam/piperacillin (TAZ/PIPC) has been shown to be effective in treating moderate-to-severe aspiration pneumonia, including nursing home-acquired pneumonia, with a clinical response rate similar to that of imipenem/cilastatin (IPM/CS) 4.
- Piperacillin/tazobactam is also effective against Pseudomonas aeruginosa infections, including those resistant to imipenem, and can be used as an alternative to carbapenems or other antipseudomonal antibiotics 5, 6.
- The use of antipseudomonal antibiotics, including piperacillin/tazobactam, should be guided by clinical judgment and local epidemiology, taking into account factors such as prior hospitalization, ICU admission, and severity of illness 7.
- Combination therapy with a beta-lactam antibiotic, such as piperacillin/tazobactam or cefepime, and an aminoglycoside or fluoroquinolone may be effective against Pseudomonas aeruginosa infections, although the choice of combination should be individualized based on patient factors and local resistance patterns 8.