Guidelines
Hospital-Acquired Pneumonia

Hospital-Acquired Pneumonia

Notes

  • Radiographic infiltrate, AND
  • 2 of 3 clinical features:
    • Fever (>38ºC or >100.4ºF)
    • Leukocytosis or leukopenia
    • Purulent sputum
  • HAP: Symptom onset occurring ≥48hrs after hospital admission
  • VAP: Symptom onset occurring ≥48hrs after endotracheal intubation
  • CXR
  • Vitals
  • ABG/O₂ sat
  • CBC
  • Respiratory GS and culture
  • Blood culture x 2 sites
  • S. pneumoniae and Legionella urinary antigens
  • MRSA nasal swab for PCR
  • Influenza A & B PCR
  • All dosages provided assume normal renal and hepatic function
  • Use of clinical judgment is encouraged when selecting empiric therapy for a patient, including consideration of severity of illness, prior microbiology, and prior antimicrobial history
  • Revise antimicrobial regimen based on microorganism identification (e.g. culture, PCR) and antimicrobial susceptibility testing results

APBL: Antipseudomonal beta-lactam AMC: Amoxicillin-clavulanate FEP: Cefepime CRO: Ceftriaxone CAZ: Ceftazidime TZP: Piperacillin-tazobactam

Empiric Treatment Recommendations

Risk factors include:

  • Interstitial lung disease (e.g. severe pulmonary fibrosis, but excluding COPD or asthma)
  • Prior use (duration ≥48 hrs, excludes one-time doses and/or most surgical prophylaxis) of non-APBL within last 3-30 days (e.g. AMC, CRO)
  • Prior airway colonization with P. aeruginosa susceptible to APBL (e.g. TZP, FEP, CAZ) within the last 12 months
  • Severe immune compromise:
    • Neutropenia [ANC <500 cells/mm³]
    • HIV/AIDS [CD4 <200 cells/mm³]
    • Immunocompromising medications within the last 30 days
    • High-dose corticosteroids of ≥20mg daily
    • Prednisone-equivalents ≥1 week
    • Chemotherapy
    • Calcineurin inhibitors
  • Prolonged hospitalization of >5 days at symptom onset

Risk factors include:

  • Cystic fibrosis or bronchiectasis
  • Prior APBL use for ≥48hrs (excludes one-time doses and/or most surgical prophylaxis) within 3-30 days (e.g. TZP, FEP, CAZ)
  • Prior airways colonization with P. aeruginosa resistant to APBL (e.g. TZP, FEP, CAZ) within the last 12 months

Additional Information

  • Given the importance of fluoroquinolones in the management of serious infections and their relative toxicity (e.g. dysglycemias, CNS side effects, muscle injury, tendonitis) compared to alternative agents, it is recommended to reserve fluoroquinolones for select patient cases where benefit outweighs the risk (e.g. severe beta-lactam allergy, oral antipseudomonal coverage)
  • Avoid levofloxacin for gram-negative bacterial coverage if patient had prior fluoroquinolone use particularly within the past 3 months (risk of infections due to fluoroquinolone-resistant bacteria may persist for up to 12 months from fluoroquinolone use)
  • If tobramycin is recommended, consider replacing this agent with an antipseudomonal fluoroquinolone (i.e. ciprofloxacin or levofloxacin) in the absence of recent fluoroquinolone use within the past 3 months
  • Inhaled tobramycin may be considered in patients with renal impairment who received fluoroquinolones recently
  • This test demonstrates a negative predictive value of >95% for ruling out MRSA as a causative pathogen for pneumonia
  • This is a useful diagnostic in patients at increased risk of MRSA pneumonia at baseline (e.g. residence in a long-term care facility, wound care in the last 30 days, prior MRSA infection/colonization within 90 days)
  • This test, which is designed for upper respiratory tract infections, includes both viral and atypical bacterial targets for community-acquired pneumonia
  • If the patient is unlikely to have polymicrobial pneumonia, consider streamlining to appropriate viral pneumonia management (e.g. oseltamivir for influenza A or B virus, supportive care for rhinovirus) or atypical bacterial pneumonia management (e.g. azithromycin)

Extended-spectrum beta-lactamase producing organisms (ESBL):

  • Carbapenems are preferred in patients with high risk of pneumonia due to ESBL-producing bacteria, including:
    • Documentation of prior infections or colonization with ESBL-producing bacteria in the past 12 months
    • Receipt of multiple courses of broad-spectrum antibiotics (piperacillin-tazobactam, cefepime, etc.) in the past 90 days

Consult PHASST during business hours or an infectious diseases specialist for assistance determining optimal empirical antimicrobial therapy