IDSA guideline

1. Pneumonia
Done by :
Raniya.Khaled
@Rania1997301
Reference :
IDSA/ATS Hospital-Acquired (HAP) and Ventilator-Associated (VAP) Pneumonia
Clinical Practice Guidelines 2016
Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official
Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases
Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67.
doi:10.1164/rccm.201908-1581ST

2. Definition
• Pneumonia is Inflammation of one or both lungs, with dense
areas of lung inflammation.
• Pneumonia is frequently but not always due to infection.
• The infection may be bacterial, viral, fungal, or parasitic.
Symptoms may include fever, chills, cough with sputum
production, chest pain, and shortness of breath.
• Pneumonia is suggested by the symptoms and confirmed by
chest X-ray testing.
Raniya.Khaled
@Rania1997301

3. Causes of hospital-acquired
pneumonia
Common organisms
1. Gram-negative bacteria:
Pseudomonas aeruginosa
E. coli
Klebsiella spp.
2. Gram-positive bacteria:
S. pneumoniae
S. aureus including MRSA
Causes of community-acquired
pneumonia
Streptococcus pneumoniae
Haemophilus influenzae
Staphylococcus aureus
Klebsiella pneumoniae
Legionella pneumophila
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Chlamydophila psittaci
Coxiella burnetii
Viruses :
Several viruses can cause pneumonia in
adults, including influenza,
parainfluenza
and varicella zoster viruses
Common Organisms in Pneumonia
Raniya.Khaled
@Rania1997301

4. Pneumonia On X-ray
Raniya.Khaled
@Rania1997301

5. CURB 65 Score – Pneumonia Clinical Prediction Tool
Component Measurement Points
Confusion Altered mental status
1
Urea/BUN
Urea >7 mmol/L or
BUN >20 mg/dL 1
Respiratory
Rate
>30 breaths/min
1
Blood
Pressure
Systolic <90 or
diastolic <60 mmHg 1
Age 65 or older
1
Total Score Mortality Disposition
0-1 <5%
Can treat as
outpatient
2-3 5-15%
Consider
hospitalization
4-5
15-30% Consider ICU
Raniya.Khaled
@Rania1997301

6. Type of Pneumonia
Type of
Pneumonia
Community-acquired
pneumonia (CAP)
Hospital-acquired pneumonia
(HAP)
Ventilator-associated
pneumonia (VAP)
Definition
Pneumonia developing
outside the hospital
or<48 hours after hospital
admission
Pneumonia developing >48 hours
after hospital admission
Pneumonia developing
>48 hours after
endotracheal intubation
Risk Factors
Age >65 years
Diabetes mellitus
Asplenia
Chronic cardiovascular,
pulmonary, renal, and/or
liver disease Smoking
and/or alcohol abuse
Witnessed aspiration
COPD, ARDS, or coma
Administration of antacids, H,
antagonists,
or proton pump inhibitor
Supine position
Enteral nutrition, nasogastric tube
Reintubation, tracheostomy, or
patient transport
Head trauma, ICP monitoring
Age >60 years
MOR risk
(eg, MRSĄ, MDR Pseudomonas) if
IV antibiotic use within 90 days
As hospital acquired
+
MOR risk with IV
antibiotics in past 90
days, septic shock, ARDS
preceding VAP, acute
renal replacement
therapy preceding VAP or
5+ days of hospitalization
preceding VAP
Raniya.Khaled
@Rania1997301

7. Initial Treatment Strategies for Inpatients with Community-acquired Pneumonia
by Level of Severity and Risk for Drug Resistance
1-
Standard Regimen
Prior Respiratory
Isolation of MRSA
Prior Respiratory
Isolation of
Pseudomonas
aeruginosa
Recent
Hospitalization
and Parenteral
Antibiotics and
Recent
Hospitalization
and Parenteral
Antibiotics
and Locally Validated
Risk Factors for P.
aeruginosa
Nonsevere
inpatient
pneumonia
b-Lactam 1 macrolide
(Ampicillin 1 sulbactam
1.5–3 g every 6 hours,
cefotaxime 1–2 g every 8
hours, ceftriaxone 1–2 g
daily, or ceftaroline 600
mg every 12 hours AND
azithromycin 500 mg
daily or clarithromycin
500 mg twice daily.
or
Respiratory
fluroquinolone
(Levofloxacin 750 mg
daily
or moxifloxacin 400 mg
daily.
Add MRSA
coverage
(vancomycin15
mg/kg every 12 h,
adjust based on
levels) or
linezolid (600 mg
every 12 h).
and obtain
cultures/nasal PCR
to allow deescalation
or confirmation of
need for continued
therapy
Add coverage for P.
aeruginosa
Piperacillin-tazobactam
(4.5 g every 6 h),
cefepime (2 g every 8 h),
ceftazidime (2 g every 8
h), imipenem (500 mg
every 6 h), meropenem
(1 g every 8 h), or
aztreonam (2 g every 8
h).
and obtain cultures to
allow deescalation or
confirmation of need for
continued therapy
Obtain cultures but
withhold MRSA
coverage unless
culture results are
positive. If rapid
nasal PCR is
available, withhold
additional empiric
therapy against
MRSA if rapid
testing is negative or
add coverage if PCR
is positive and
obtain cultures
Obtain cultures but
initiate coverage
for P. aeruginosa
only if culture
results are positive
Raniya.Khaled
@Rania1997301

8. Initial Treatment Strategies for Inpatients with Community-acquired Pneumonia
by Level of Severity and Risk for Drug Resistance
2- Standard Regimen
Prior Respiratory
Isolation of MRSA
Prior Respiratory
Isolation of
Pseudomonas
aeruginosa
Recent
Hospitalization
and Parenteral
Antibiotics and
Recent
Hospitalization
and Parenteral
Antibiotics
and Locally Validated
Risk Factors for P.
aeruginosa
Severe
inpatient
pneumonia
b-Lactam 1 macrolide
or
b-lactam +
Fluroquinolone
Add MRSA coverage
and obtain
cultures/nasal PCR to
allow deescalation or
confirmation of need for
continued therapy
Add coverage for P.
aeruginosa and obtain
cultures to allow
deescalation or
confirmation of need for
continued therapy
Add MRSA coverage
and obtain nasal
PCR and cultures to
allow deescalation or
confirmation of need
for continued
therapy
Add coverage for
P. aeruginosa and
obtain cultures to
allow deescalation
or confirmation of
need for continued
therapy
Raniya.Khaled
@Rania1997301

9. Suggested Empiric Treatment Options for Clinically Suspected Ventilator-Associated Pneumonia
in Units Where Empiric Methicillin-Resistant Staphylococcus aureus Coverage and Double Antipseudomonal/Gram-Negative
Coverage Are Appropriate
Gram-Positive Antibiotics With
MRSA Activity
Gram-Negative Antibiotics With
Antipseudomonal Activity: à-Lactam–Based
Agents
Gram-Negative Antibiotics With
Antipseudomonal Activity: Non-à-
Lactam–Based Agents
Glycopeptides
Vancomycin 15 mg/kg IV q8–12h
(consider a loading dose of 25–
30 mg/kg × 1 for severe illness)
Antipseudomonal penicillins Piperacillin-
tazobactam 4.5 g IV q6h
Fluoroquinolones
Ciprofloxacin 400 mg IV q8h Levofloxacin
750 mg IV q24h
OR
Cephalosporins:
Cefepime 2 g IV q8h
Ceftazidime 2 g IV q8h
OR Aminoglycosides
Amikacin 15–20 mg/kg IV q24h
Gentamicin 5–7 mg/kg IV q24h
Tobramycin 5–7 mg/kg IV q24h
OR
Oxazolidinones:
Linezolid 600 mg IV q12h
OR
Carbapenems:
Imipenem 500 mg IV q6h Meropenem 1 g IV
q8h Polymyxins
Colistin 5 mg/kg IV × 1 (loading dose)
followed by 2.5 mg ×
(1.5 × CrCl + 30) IV q12h
(maintenance dose
Polymyxin B 2.5–3.0 mg/kg/d
divided in 2 daily IV doses
OR
Monobactams:
Aztreonam 2 g IV q8h
Raniya.Khaled
@Rania1997301

10. Recommended Initial Empiric Antibiotic Therapy for
Hospital-Acquired Pneumonia (Non-Ventilator-Associated Pneumonia)
Not at High Risk of Mortality and
no Factors Increasing the
Likelihood of MRSA
Not at High Risk of Mortality but With Factors
Increasing the Likelihood of MRSA
High Risk of Mortality or Receipt of
Intravenous Antibiotics During the Prior 90
One of the following:
Piperacillin-tazobactam
4.5 g IV q6h
OR
Cefepime 2 g IV q8h
OR
Levofloxacin 750 mg IV daily
Imipenem 500 mg IV q6h
Meropenem 1 g IV q8h
One of the following:
Piperacillin-tazobactam 4.5 g IV q6h
OR
Cefepime or ceftazidime 2 g IV q8h
OR
Levofloxacin 750 mg IV daily
Ciprofloxacin 400 mg IV q8h
OR
Imipenem 500 mg IV q6h
Meropenem 1 g IV q8h
OR
Aztreonam 2 g IV q8h
Plus
Vancomycin 15 mg/kg IV q8–12h with goal to
target
15–20 mg/mL trough level (consider a loading
dose of 25–30 mg/kg × 1 for severe illness)
OR
Linezolid 600 mg IV q12h
Two of the following, avoid 2 à-lactams
Piperacillin-tazobactam 4.5 g IV q6h
OR
Cefepime or ceftazidime 2 g IV q8h
OR
Levofloxacin 750 mg IV daily
Ciprofloxacin 400 mg IV q8h
OR
Imipenem 500 mg IV q6h
Meropenem 1 g IV q8h
OR
Amikacin 15–20 mg/kg IV daily
Gentamicin 5–7 mg/kg IV daily
Tobramycin 5–7 mg/kg IV daily
OR
Aztreonam 2 g IV q8h
Plus:
Vancomycin 15 mg/kg IV q8–12h with goal to
target 15–20 mg/mL
trough level (consider a loading dose of 25–30
mg/kg IV × 1 for severe illness)
OR
Linezolid 600 mg IV q12h
Raniya.Khaled
@Rania1997301

11. Recommended Initial Empiric Antibiotic Therapy for
Hospital-Acquired Pneumonia (Non-Ventilator-Associated Pneumonia)
Not at High Risk of Mortality and
no Factors Increasing the
Likelihood of MRSA
Not at High Risk of Mortality but With Factors
Increasing the Likelihood of MRSA
High Risk of Mortality or Receipt of
Intravenous Antibiotics During the Prior 90
One of the following:
Piperacillin-tazobactam
4.5 g IV q6h
OR
Cefepime 2 g IV q8h
OR
Levofloxacin 750 mg IV daily
Imipenem 500 mg IV q6h
Meropenem 1 g IV q8h
One of the following:
Piperacillin-tazobactam 4.5 g IV q6h
OR
Cefepime or ceftazidime 2 g IV q8h
OR
Levofloxacin 750 mg IV daily
Ciprofloxacin 400 mg IV q8h
OR
Imipenem 500 mg IV q6h
Meropenem 1 g IV q8h
OR
Aztreonam 2 g IV q8h
Plus
Vancomycin 15 mg/kg IV q8–12h with goal to
target
15–20 mg/mL trough level (consider a loading
dose of 25–30 mg/kg × 1 for severe illness)
OR
Linezolid 600 mg IV q12h
Two of the following, avoid 2 à-lactams
Piperacillin-tazobactam 4.5 g IV q6h
OR
Cefepime or ceftazidime 2 g IV q8h
OR
Levofloxacin 750 mg IV daily
Ciprofloxacin 400 mg IV q8h
OR
Imipenem 500 mg IV q6h
Meropenem 1 g IV q8h
OR
Amikacin 15–20 mg/kg IV daily
Gentamicin 5–7 mg/kg IV daily
Tobramycin 5–7 mg/kg IV daily
OR
Aztreonam 2 g IV q8h
Plus:
Vancomycin 15 mg/kg IV q8–12h with goal to
target 15–20 mg/mL
trough level (consider a loading dose of 25–30
mg/kg IV × 1 for severe illness)
OR
Linezolid 600 mg IV q12h