From the Guidelines
Hospital-acquired pneumonia (HAP) should be treated with empiric antibiotic therapy started promptly after obtaining appropriate cultures, with a recommended regimen including a combination of an antipseudomonal β-lactam and either an antipseudomonal fluoroquinolone or an aminoglycoside, and treatment duration typically lasting 7 days, with de-escalation of antibiotics once culture results are available, as supported by the most recent guidelines 1.
Key Recommendations
- Empiric antibiotic therapy should be started promptly after obtaining appropriate cultures for HAP patients.
- The recommended regimen for non-ventilated HAP includes a combination of an antipseudomonal β-lactam (such as piperacillin-tazobactam, cefepime, or meropenem) plus either an antipseudomonal fluoroquinolone (such as levofloxacin) or an aminoglycoside (such as amikacin) 1.
- For ventilator-associated pneumonia, similar regimens are used but with consideration for adding vancomycin or linezolid if MRSA is suspected.
- Treatment duration is typically 7 days, but may be extended based on clinical response.
- De-escalation of antibiotics should occur once culture results are available.
Prevention Strategies
- Elevation of the head of the bed to reduce the risk of aspiration.
- Oral care with chlorhexidine to reduce the risk of infection.
- Minimizing sedation with daily sedation interruptions to reduce the risk of complications.
Importance of Guidelines
The guidelines published by the European Respiratory Society (ERS) and other organizations provide a framework for the management of HAP and ventilator-associated pneumonia (VAP), and emphasize the importance of prompt empiric antibiotic therapy, de-escalation of antibiotics, and prevention strategies to reduce the risk of infection and improve patient outcomes 1.
Recent Studies
Recent studies have highlighted the importance of using local microbiologic data to guide antibiotic therapy, and the need for ongoing surveillance and monitoring to prevent the emergence of multidrug-resistant bacteria 1.
Clinical Judgment
It is essential to use clinical judgment when managing patients with HAP, taking into account individual patient factors, such as underlying medical conditions, and the results of cultures and other diagnostic tests 1.
Morbidity, Mortality, and Quality of Life
The management of HAP should prioritize reducing morbidity, mortality, and improving quality of life, by using evidence-based guidelines, and individualizing treatment to each patient's needs 1.
From the FDA Drug Label
- 2 Nosocomial Pneumonia 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) [see Dosage and Administration (2)].
Piperacillin-tazobactam is indicated for the treatment of nosocomial pneumonia (moderate to severe) in adults and pediatric patients (2 months of age and older) caused by specific bacteria, including Staphylococcus aureus, Acinetobacter baumannii, Haemophilus influenzae, Klebsiella pneumoniae, and Pseudomonas aeruginosa. The recommended dosage for nosocomial pneumonia is 4.5 grams every six hours plus an aminoglycoside 2.
From the Research
Definition and Risk Factors
- Hospital-acquired pneumonia (HAP) is a form of nosocomial pneumonia that complicates hospitalization in 0.5 to 2.0% of patients and is associated with considerable morbidity and mortality 3.
- Risk factors for HAP include mechanical ventilation for > 48 h, residence in an ICU, duration of ICU or hospital stay, severity of underlying illness, and presence of comorbidities 3.
Microbiology and Treatment
- The most common causes of HAP are Pseudomonas aeruginosa, Staphylococcus aureus, and Enterobacter, with nearly half of HAP cases being polymicrobial 3.
- Optimal therapy for HAP should take into account severity of illness, demographics, specific pathogens involved, and risk factors for antimicrobial resistance 3.
- For pseudomonal HAP, combination therapy with an antipseudomonal beta-lactam plus an aminoglycoside or a fluoroquinolone is recommended 3.
- A locally-derived empiric algorithm based on local microbiologic data can predict more accurate coverage than a guideline-driven approach 4.
Comparison of Treatment Options
- Piperacillin/tazobactam has been shown to be more effective than ceftriaxone plus clindamycin in the treatment of early, non-ventilator HAP 5.
- The use of broad-spectrum antibiotics in the treatment of HAP is recommended, but not all patients may require antipseudomonal therapy 6.
- An algorithm modified from the European guideline proposes an approach to therapy that necessitates dual antipseudomonal therapy in less than 25% of all HAP patients 6.
Antibiotic Stewardship
- The overuse of broad-spectrum antibiotics can lead to antibiotic resistance, and effective policies of de-escalation are needed to avoid this risk 7.
- The use of narrow-spectrum antibiotics is recommended, and informed clinical judgement and the application of biomarkers can help guide antibiotic therapy 7.