What are the guidelines for Hospital-Acquired Pneumonia (HAP)?

From the Guidelines

Hospital-acquired pneumonia should be treated with empiric broad-spectrum antibiotics, with the initial choice based on the patient's risk of mortality and likelihood of methicillin-resistant Staphylococcus aureus (MRSA) infection, as outlined in the 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society 1. For patients not at high risk of mortality and without factors increasing the likelihood of MRSA, recommended initial empiric antibiotic therapy includes 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. Key considerations in the management of hospital-acquired pneumonia include:

• Identifying patients at high risk of mortality or with recent intravenous antibiotic use, who may require broader coverage with two antibiotics, avoiding two β-lactams, and including options like vancomycin for MRSA coverage or alternatives for methicillin-susceptible Staphylococcus aureus (MSSA) coverage.
• The importance of tailoring therapy based on local antibiogram data and individual patient risk factors for multidrug-resistant organisms.
• Implementing preventive measures such as head-of-bed elevation, oral care with chlorhexidine, and early mobilization to reduce the risk of hospital-acquired pneumonia.
• Obtaining respiratory cultures before starting antibiotics when possible to guide de-escalation of therapy based on culture results after 48-72 hours. Treatment duration is typically 7 days, with a focus on balancing adequate treatment with minimizing adverse effects and the emergence of antibiotic resistance, as recommended in the guidelines 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).

In clinically and microbiologically evaluable patients with documented Pseudomonas aeruginosa infection, 15 of 17 (88.2%) received ceftazidime (N = 11) or piperacillin/tazobactam (N = 4) in the levofloxacin arm and 16 of 17 (94. 1%) received an aminoglycoside in the comparator arm.

The hospital acquired pneumonia guideline recommends the use of piperacillin and tazobactam at a dosage of 4.5 grams every six hours plus an aminoglycoside for the initial presumptive treatment of patients with nosocomial pneumonia 2 2. Additionally, levofloxacin may be used as an alternative treatment option, with a dosage of 750 mg once daily for 7 to 15 days 3. It is essential to note that the treatment regimen may vary depending on the patient's condition, renal function, and the causative pathogen.

• The treatment of nosocomial pneumonia should be guided by the results of microbiological tests and clinical evaluations.
• Piperacillin and tazobactam and levofloxacin have been shown to be effective against a range of pathogens, including Pseudomonas aeruginosa and multi-drug resistant Streptococcus pneumoniae.
• The use of adjunctive therapy, such as vancomycin or an aminoglycoside, may be necessary in certain cases, such as suspected methicillin-resistant S. aureus infection or Pseudomonas aeruginosa infection.

From the Research

Hospital-Acquired Pneumonia Guideline

• Hospital-acquired pneumonia (HAP) is a potentially serious infection that primarily affects older patients, with an increasing number of patients affected by multidrug-resistant (MDR) bacteria 4.
• The current recommended guidelines for the management of HAP discuss the use of empirical therapy, including antibiotics such as piperacillin-tazobactam, cefepime, carbapenems, or fluorquinolones for patients not at risk of MDR organism infection 4.
• For patients at risk of HAP infection by MDR strains, broader-spectrum empiric antibiotic therapies that target P. aeruginosa and methicillin-resistant S. aureus are recommended 4.

Antibiotic Treatment

• The choice of antibiotic treatment requires consideration of local and national resistance data, as well as the patient's risk factors, such as underlying diseases, antibiotic pretreatment, or mechanical ventilation 5.
• Combination therapy with an anti-pseudomonal beta-lactam and a fluoroquinolone or an aminoglycoside is recommended for patients with severe pneumonia or septicemia and risk factors 5.
• Monotherapy regimens, such as piperacillin-tazobactam, cefepime, or carbapenems, may be effective in some cases, but the choice of therapy should be guided by the patient's specific risk factors and the local epidemiology of antibiotic resistance 5, 6.

Heterogeneity of Hospital-Acquired Pneumonia

• Hospital-acquired pneumonia is a heterogeneous disease, and not all patients require the same broad-spectrum antibiotic therapy as complex nosocomial pneumonia 7.
• Patients with HCAP (healthcare-associated pneumonia) may be at risk for multidrug-resistant organisms, but others may not, and the choice of therapy should be guided by the patient's specific risk factors 7.
• An algorithm for empiric therapy of HCAP has been proposed, which suggests that not all patients require a broad-spectrum multidrug regimen 7.

Comparison with Ventilator-Associated Pneumonia

• Hospital-acquired pneumonia is distinct from ventilator-associated pneumonia (VAP), with differences in natural history, risk factors, and bacteriology that necessitate a different approach to therapy 8.
• The American guidelines recommend broader spectrum therapy than the European guidelines, but recent studies support the idea that not all HAP patients need antipseudomonal therapy 8.
• 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 8.