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

From the Guidelines

Hospital-acquired pneumonia treatment should be initiated with empiric broad-spectrum antibiotics, prioritizing coverage for multidrug-resistant organisms, with a recommended combination of an antipseudomonal beta-lactam and a respiratory fluoroquinolone or an aminoglycoside, and adding MRSA coverage if necessary, as outlined in the 2017 international ERS/ESICM/ESCMID/ALAT guidelines 1. The choice of antibiotics depends on the patient's risk factors for mortality and multidrug-resistant (MDR) pathogens.

• For patients not at high risk of mortality and without factors increasing the likelihood of MRSA, 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, as recommended by the 2016 IDSA/ATS guidelines 1.
• For patients at high risk of mortality or with recent intravenous antibiotic exposure, a combination of two agents, including an antipseudomonal beta-lactam and an aminoglycoside or a respiratory fluoroquinolone, is recommended, with consideration for MRSA coverage using vancomycin or linezolid 1. Key considerations in selecting empiric antibiotics include local resistance patterns, patient-specific factors such as kidney function, and the presence of risk factors for specific pathogens, such as MRSA or Pseudomonas aeruginosa.
• The treatment duration is typically 7 days but may be extended based on clinical response, and therapy should be de-escalated once culture results are available, targeting the specific pathogens identified 1. Supportive care, including oxygen therapy, respiratory support, and fluid management, is essential in the management of hospital-acquired pneumonia.
• The 2017 international ERS/ESICM/ESCMID/ALAT guidelines provide a comprehensive approach to the management of hospital-acquired pneumonia, emphasizing the importance of assessing the risk for MDR pathogens and mortality, and selecting empiric antibiotics accordingly 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 g every six hours plus an aminoglycoside, totaling 18 g (16 g piperacillin/2 g 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.

Hospital Acquired Pneumonia Treatment:

• Piperacillin and tazobactam for injection can be used at a dosage of 4.5 g every six hours plus an aminoglycoside for the initial presumptive treatment of nosocomial pneumonia 2.
• Levofloxacin tablets are indicated for the treatment of nosocomial pneumonia due to certain microorganisms, including methicillin-susceptible Staphylococcus aureus, Pseudomonas aeruginosa, and others 3. Key Considerations:
• The choice of treatment should be based on the suspected or confirmed causative microorganisms and their susceptibility patterns.
• Combination therapy with an anti-pseudomonal β-lactam is recommended when Pseudomonas aeruginosa is a documented or presumptive pathogen 3.

From the Research

Hospital Acquired Pneumonia Treatment

• 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 suggest the use of antibiotics such as piperacillin-tazobactam, cefepime, carbapenems, or fluorquinolones in patients not at risk of MDR organism infection 4.
• However, in 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, 5.
• A study comparing the clinical benefits of piperacillin/tazobactam versus a combination of ceftriaxone and clindamycin in the treatment of early, non-ventilator, hospital-acquired pneumonia found that treatment with piperacillin/tazobactam was more effective than that with ceftriaxone plus clindamycin 6.
• Another study suggested that initial therapy for HCAP should include antibiotics targeting MRSA and P. aeruginosa in order to provide appropriate initial therapy, but the selection of individual antibiotic agents should be based on local patterns of infection and adjusted when microbiology results become available 5.
• A study on the transition from broad-spectrum intravenous antibiotics to oral antibiotics in patients with health care-associated pneumonia found that switching to a narrow-spectrum oral antibiotic once clinical stability is achieved may be safe, but further studies are needed to confirm this observation 7.
• The approach to therapy for HAP may differ from that of ventilator-associated pneumonia (VAP), with some studies suggesting that not all HAP patients need antipseudomonal therapy 8.