Hospital-acquired (or nosocomial) pneumonia (HAP)

1. Hospital-acquired (or nosocomial) pneumonia (HAP)
Empiric coverage for patients WITHOUT
risk factors for MDR pathogens
•Pneumonia that occurs 48
hours or more after
admission and did not
appear to be incubating at
the time of admission.
Empiric coverage for patients WITH risk factors for
MDR pathogens
One of the following intravenous (IV) antibiotic regimens:
●Ceftriaxone (2 g IV daily)
●Ampicillin-sulbactam (3 g intravenously every six hours)
●Levofloxacin (750 mg IV daily) or moxifloxacin (400 mg IV
daily). When the patient is able to take oral medications, either
agent may be administered orally at the same dose as that used
for IV administration.
●Ertapenem (1 g IV daily)
●Choice of a specific agent for empiric therapy should be based
upon knowledge of the prevailing pathogens (and susceptibility
patterns) within the healthcare setting. If there is concern for
gram-negative bacilli resistant to the above options
(eg, Enterobacter spp, Serratia spp, Pseudomonas spp) based
upon microbiologic data at the specific institution, we feel that it
is reasonable to initiate piperacillin-tazobactam (4.5 g IV every
six hours) or another agent (eg, cefepime or an
antipseudomonal carbapenem [imipenem, meropenem]) as
monotherapy for patients without known risk factors for MDR
bacteria, provided that the institution’s susceptibility data support
in vitro activity.
One of the following:
•Antipseudomonal cephalosporin such as cefepime (2 g IV every eight hours) or
ceftazidime (2 g IV every eight hours)
•Antipseudomonal carbapenem such as imipenem (500 mg to 1 g IV every six
hours) or meropenem (1 g IV every eight hours)
•Piperacillin-tazobactam (4.5 g IV every six hours)
•For patients who are allergic to penicillin, the type and severity of reaction should
be assessed. If a skin test is positive or if there is significant concern to warrant
avoidance of a cephalosporin or carbapenem, aztreonam (2 g IV every six to eight
hours) is recommended.
PLUS consider one of the following (if microbiologic data from the institution or the
patient’s previous cultures suggest that one of the following agents provides
necessary additional coverage for gram-negative bacilli in combination with the
selected beta-lactam):
•Antipseudomonal fluoroquinolone, such as ciprofloxacin (400 mg IV every eight
hours) or levofloxacin (750 mg IV daily)
•Aminoglycoside such as gentamicin or tobramycin (7 mg/kg i IV once daily) or
amikacin(20 mg/kg IV once daily). The aminoglycoside can be stopped after five to
seven days in responding patients.
•Addition of an alternative agent, such as IV colistin, may be appropriate if highly
resistantPseudomonas spp or Acinetobacter spp is suspected. In some cases,
inhaled colistin may be appropriate as adjunctive therapy in combination with
systemic antimicrobials.
PLUS one of the following (if MRSA is suspected, there are MRSA risk factors, or
there is a high incidence of MRSA locally):
•Linezolid (600 mg iV every 12 hours; may be administered orally when the patient
is able to take oral medications)
•Vancomycin (15 to 20 mg/kg [based on actual body weight] IV every 8 to 12 hours
for patients with normal renal function, with a target serum trough concentration of
15 to 20 mg/L.) In seriously ill patients, a loading dose of 25 to 30 mg/kg can be
used to facilitate rapid attainment of the target trough concentration.
•Telavancin (10 mg/kg IV every 24 hours) is an alternative agent when neither
linezolid nor vancomycin can be used, but there are several boxed warnings that
must be considered before choosing it.