What are the recommended antibiotics for Hospital-Acquired Community-Acquired Pneumonia (HCAP) pneumonia?

From the Guidelines

For healthcare-associated pneumonia (HCAP), empiric antibiotic therapy should include coverage for both typical community-acquired pneumonia pathogens and potential drug-resistant organisms, with a recommended regimen being piperacillin-tazobactam 4.5g IV every 6 hours or cefepime 2g IV every 8 hours, plus either levofloxacin 750mg IV daily or an aminoglycoside, and coverage for MRSA with vancomycin 15-20mg/kg IV every 8-12 hours or linezolid 600mg IV every 12 hours, as outlined in the 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society 1.

Key Considerations

• The choice of empiric antibiotic therapy for HCAP depends on the patient's risk of mortality and factors that increase the likelihood of methicillin-resistant Staphylococcus aureus (MRSA) 1.
• For patients not at high risk of mortality and without factors increasing the likelihood of MRSA, options include piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem 1.
• For patients at high risk of mortality or with recent intravenous antibiotic use, a combination of two antibiotics, including an anti-pseudomonal beta-lactam and an aminoglycoside, plus coverage for MRSA, is recommended 1.
• Therapy should be de-escalated based on culture results and clinical improvement, and patients should be reassessed within 48-72 hours to evaluate clinical response and potentially narrow therapy 1.

Treatment Duration and De-escalation

• Treatment duration is typically 7-14 days, depending on clinical response and pathogen identified 1.
• Respiratory cultures should be obtained before starting antibiotics whenever possible to guide targeted therapy and reduce unnecessary broad-spectrum coverage 1.
• Patients with severe penicillin allergy may require alternative regimens, including aztreonam, and coverage for MSSA should be included if MRSA coverage is not used 1.

From the FDA Drug Label

1.1 Nosocomial Pneumonia 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 antibiotic of choice for HCAP (Healthcare-Associated Pneumonia) pneumonia is not explicitly stated in the label, but nosocomial pneumonia is mentioned, which can be considered similar.

• Levofloxacin is indicated for the treatment of nosocomial pneumonia due to several microorganisms, including Pseudomonas aeruginosa and Streptococcus pneumoniae.
• However, it is essential to note that HCAP pneumonia may require a different treatment approach than nosocomial pneumonia, and the label does not provide direct guidance on this specific condition 2.

From the Research

Antibiotics for HCAP Pneumonia

• The use of antibiotics for Hospital-Acquired Community Pneumonia (HCAP) is a topic of interest, with various studies examining the efficacy of different antibiotic regimens 3, 4, 5, 6.
• A study published in 2004 compared the efficacy and tolerability of intravenous azithromycin plus ceftriaxone and intravenous levofloxacin with step-down oral therapy for hospitalized patients with moderate to severe community-acquired pneumonia, finding that both treatments were well tolerated and had favorable clinical outcomes 3.
• Another study published in 2020 compared the clinical benefits of piperacillin/tazobactam versus a combination of ceftriaxone and clindamycin in the treatment of early, non-ventilator, hospital-acquired pneumonia, finding that treatment with piperacillin/tazobactam was more effective than that with ceftriaxone plus clindamycin 4.
• A systematic review and network meta-analysis published in 2021 identified the empiric antibiotic with the highest probability of being the best in terms of cure rate and mortality rate in hospitalized patients with community-acquired pneumonia, finding that ceftaroline and piperacillin had the highest probability of being the best for cure rate, while ceftriaxone plus levofloxacin, ertapenem, and amikacin plus clarithromycin had the highest probability of being the best for mortality rate 5.
• A prospective randomized trial published in 2018 compared the efficacy of oral levofloxacin versus a combination of parenteral ceftriaxone and oral azithromycin in the treatment of community-acquired pneumonia in hospitalized patients, finding that monotherapy with oral levofloxacin was as effective as treatment with ceftriaxone plus azithromycin combination 6.
• A review published in 2020 provided updated empirical dosing strategies for antimicrobial agents during continuous renal replacement therapy, including recommendations for ceftriaxone, levofloxacin, and other antibiotics 7.

Key Findings

• The choice of antibiotic regimen for HCAP pneumonia depends on various factors, including the severity of the disease, the presence of comorbidities, and the risk of antibiotic resistance 3, 4, 5, 6.
• Combination therapy with a beta-lactam antibiotic and a macrolide or fluoroquinolone may be effective for the treatment of HCAP pneumonia, but the choice of specific antibiotics and the duration of therapy should be individualized based on the patient's clinical condition and the results of microbiological tests 3, 4, 5, 6.
• Antimicrobial dosing optimization during continuous renal replacement therapy is crucial to ensure effective treatment and prevent drug resistance, and updated dosing strategies are available for various antibiotics, including ceftriaxone and levofloxacin 7.