IDSA/hivma 2016 guideline of HAP (VAP not included)

1. PGY 李翰泓/Supervisor 林詩萍 醫師

2. The Difference between
the 2016 and 2005 Version

3. • The use of the Grading of Recommendations Assessment,
Development and Evaluation (GRADE) for all evidence
• Removal of the concept healthcare-associated
pneumonia (HCAP)
• Guide for the optimal choice of antibiotics according to
each specific antibiograms

5. Why is HCAP removed?
• High risk for MDR organisms?
• Underlying characteristics also as independent
determinants
• Might include into the upcoming community-acquired
pneumonia (CAP)
• Both initially cared for in ER
• Coverage of MDR pathogens depend on validated risk

6. Definitions

7. Hospital-Acquired
Pneumonia
• Pneumonia not intubating at the time of admission
• Occurring ≧48 hrs after admission
• Not associated with mechanical ventilation (MV)

8. HAP
• Most common hospital-acquired infection (HAI): 22%
• HAP: serious complications in 50% of patients

9. Microbiologic Methods
to Diagnose HAP

10. Treatment
• Based on _______ sampling with _______ culture results?
A. Invasive; quantitative
B. Noninvasive; quantitative
C. Noninvasive; semiquantitative

11. • Non-invasive sampling with semi quantitative cultures
• Invasive: bronchoscopic techniques (bronchoalveolar
lavage (BAL), protected specimen brush (PSB), mini-
BAL)
• Noninvasive: endotracheal aspiration

12. If Invasive Quantitative
Cultures are Performed…
• If results below the diagnostic threshold (PSB <10^3
Colony-Forming Units [CFU]/ml, BAL <10^4 CFU/ml),
should antibiotic treatment…
A. Withheld
B. Continued

13. • Noninvasive sampling with semiquantitative cultures as
the preference
• Antibiotics withheld rather than continued
• Clinical factors should be considered!
• Avoiding unnecessary harm and cost

14. If Patients with Suspected
HAP (Non-VAP)…
• Should treatment be guided by…
A. Microbiologic studies of respiratory samples
B. Be empiric

15. • Results of microbiologic studies of respiratory samples,
which obtained NONINVASIVELY
• deescalate the therapy based upon respiratory and
blood culture results
• Non-invasive methods: spontaneous expectoration, sputum
induction, nasaltracheal suction, endotracheal aspiration

16. The Use of Biomarkers and the
Clinical Pulmonary Infection
Score to Diagnose HAP

17. For Patients with
Suspected HAP…
• Should the initiation of antibiotic therapy be based on
_______?
A. Clinical criteria + Procalcitonin (PCT)
B. Clinical criteria alone

18. • Clinical criteria ALONE

19. For Patients with
Suspected HAP…
• Should the initiation of antibiotic therapy be based on
_______?
A. Clinical criteria + C-Reactive Protein (CRP)
B. Clinical criteria alone

20. • Clinical criteria ALONE

21. For Patients with
Suspected HAP…
• Should the initiation of antibiotic therapy be based on
_______?
A. Clinical criteria + Modified Clinical Pulmonary
Infection Score (CPIS)
B. Clinical criteria alone

22. Temperature
White blood cell count
Tracheal secretions
Oxygenation, PaO2/FiO2 mmHg
Pulmonary radiography
Culture of tracheal aspirate specimen

23. • Clinical criteria ALONE

24. Initial Treatment of
HAP

25. Selection of the regimen
for HAP…
• Should them be guided by local antibiotic-resistance
data?
A. Yes
B. No

26. • Generate and disseminate a local antibiogram, specific
to each HAP population ideally
• Treatment informed by local distribution of pathogens
and their susceptibilities

27. What Antibiotics are
Recommended…
• For clinically suspected HAP (non-VAP)?

28. • Not at High Risk of Mortality and no Factors Increasing
the Likelihood of MRSA
ONE OF THE FOLLOWING
Piperacillin-tazobactam 4.5g IV q6h
OR
Cefepime 2g IV q8h
OR
Levofloxacin 750mg IV daily
Imipenem 500mg IV q6h
Meropenem 1g IV q8h

29. • Not at High Risk of Mortality but with Factors Increasing
the Likelihood of MRSA
ONE OF THE FOLLOWING
Piperacillin-tazobactam 4.5g IV q6h
OR
Cefepime or ceftazidime 2g IV q8h
OR
Levofloxacin 750mg IV daily
Ciprofloxacin 400mg IV q8h
OR
Imipenem 500mg IV q6h
Meropenem 1g IV q8h
OR
Aztreonam 2g 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 600mg IV q12h

30. •If patient has severe penicillin allergy and aztreonam is
going to be used insead of any β-lactam-based antibiotic,
include coverage for MSSA

31. • High Risk of Mortality or Receipt of Intravenous Antibiotics
During the Prior 90 d
TWO OF THE FOLLOWING, AVOID 2 β-LACTAMS
Piperacillin-tazobactam 4.5g IV q6h
OR
Cefepime or ceftazidime 2g IV q8h
OR
Levofloxacin 750mg IV daily
Ciprofloxacin 400mg IV q8h
OR
Imipenem 500mg IV q6h
Meropenem 1g 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 2g 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 600mg IV q12h

32. •If MRSA coverage is not going to be used, include
coverage for MSSA
•Piperacillin-tazobactam, cefepime, levofloxacin,
imipenam, meropenem
•Oxacillin, nafcillin and cefazolin are preferred for the
treatment of proven MSSA
•Not ordinary used in an empiric regimen for HAP

33. •If patient has severe penicillin allergy and aztreonam is
going to be used insead of any β-lactam-based antibiotic,
include coverage for MSSA

34. • Recommend coverage of S.aureus
• Recommend coverage of P.aeruginosa and other G(-)
bacilli

35. • MRSA: only for
• risky patients
• > 20% S.aureus isolated are methicillin-resistant
• MRSA prevalance unknown
• High risk for mortality (include need for MV due to
HAP and septic shock)

36. • For MRSA: Vancomycin or Linezolid
• For MSSA: Tazocin, cefepime, levofloxacin, imipenem,
meropenem
• Oxacillin, nafcillin or cefazolin only for proven MSSA

37. • Antipseudomonal antibiotics: 2 agents from different
classes, only for:
• risky patients
• High risk for mortality
• include need for MV due to HAP and septic shock
• Patients with structural lung disease
• bronchiectasis, cystic fibrosis
• Else: single agent

38. • Avoid aminoglycosides as the sole antipseudomonal
agent

40. Pathogen-Specific
Therapy

41. What Antibiotics should
be used for…
• MRSA HAP?

42. • Vancomycin or linezolid
• Guided by CBC, serotonin-reuptake inhibitors, renal
function, cost
• SRI+linezolid: serotonin syndrome!!!

43. What Antibiotics should
be used for…
• P. aeruginosa HAP?

44. • Based upon the results of antimicrobial susceptibility
testing
• DO NOT USE AMINOGLYCOSIDE MONOTHERAPY

45. For P.aeruginosa HAP
• Which therapy is applicable?
A. Monotherapy
B. Combination therapy

46. Monotherapy
• Not in septic shock
• Not at high risk for death
• Antibiotic susceptibility testing are known

47. Combination Therapy
• In septic shock
• High risk for death (mortality > 25%)
• Antibiotic susceptibility testing unknown
• DO NOT CONTINUE COMBINATION THERAPY after shock
subsided but susceptibility unknown

48. • DO NOT USE AMINOGLYCOSIDE MONOTHERAPY
• DO NOT USE AMINOGLYCOSIDE MONOTHERAPY
• DO NOT USE AMINOGLYCOSIDE MONOTHERAPY

49. • Not at High Risk of Mortality and no Factors Increasing
the Likelihood of MRSA
ONE OF THE FOLLOWING
Piperacillin-tazobactam 4.5g IV q6h
OR
Cefepime 2g IV q8h
OR
Levofloxacin 750mg IV daily
Imipenem 500mg IV q6h
Meropenem 1g IV q8h

50. • Not at High Risk of Mortality but with Factors Increasing
the Likelihood of MRSA
ONE OF THE FOLLOWING
Piperacillin-tazobactam 4.5g IV q6h
OR
Cefepime or ceftazidime 2g IV q8h
OR
Levofloxacin 750mg IV daily
Ciprofloxacin 400mg IV q8h
OR
Imipenem 500mg IV q6h
Meropenem 1g IV q8h
OR
Aztreonam 2g 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 600mg IV q12h

51. •If patient has severe penicillin allergy and aztreonam is
going to be used insead of any β-lactam-based antibiotic,
include coverage for MSSA

52. • High Risk of Mortality or Receipt of Intravenous Antibiotics
During the Prior 90 d
TWO OF THE FOLLOWING, AVOID 2 β-LACTAMS
Piperacillin-tazobactam 4.5g IV q6h
OR
Cefepime or ceftazidime 2g IV q8h
OR
Levofloxacin 750mg IV daily
Ciprofloxacin 400mg IV q8h
OR
Imipenem 500mg IV q6h
Meropenem 1g 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 2g 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 600mg IV q12h

53. •If MRSA coverage is not going to be used, include
coverage for MSSA
•Piperacillin-tazobactam, cefepime, levofloxacin,
imipenam, meropenem
•Oxacillin, nafcillin and cefazolin are preferred for the
treatment of proven MSSA
•Not ordinary used in an empiric regimen for HAP

54. •If patient has severe penicillin allergy and aztreonam is
going to be used insead of any β-lactam-based antibiotic,
include coverage for MSSA

55. What Antibiotics should
be used for…
• Acinetobacter species HAP?

56. • Carbapenem or ampicillin/sulbactam
• If the isolate susceptible
• IV colistin or polymyxin B
• adjunctive inhaled colistin
• If the isolate only sensitive to polymyxins

57. • For patients with Acinetobacter only sensitive to colistin
• Do not use adjunctive rifampicin
• DO NOT USE TIGECYCLINE

58. What Antibiotics should
be used for…
• Carbapenem-Resistant pathogens HAP?

59. • IV colistin or polymyxin B
• adjunctive inhaled colistin
• If the isolate only sensitive to polymyxins
• Inhaled colistin > inhaled polymyxin B
• IV polymyxin B > IV colistin

60. Length of Therapy

61. How long should the
duration of treatment be…
• For patients with HAP (non-VAP)?
A. 7 days
B. 8-15 days

62. • 7 days
• Depending upon the clinical, radiological or laboratory
condition

63. Should the antibiotics
treatment…
• Be _______ in patients with HAP?
A. Fixed
B. De-escalated

64. • De-escalated > fixed
• Empiric broad-spectrum antibiotics -> narrower
antibiotic regimen
• Combination therapy -> monotherapy

65. Should the discontinuation
of antibiotics therapy…
• Be based on _______
A. PCT level + clinical criteria
B. Clinical criteria alone

66. • PCT level + clinical criteria

67. Should the discontinuation
of antibiotics therapy…
• Be based on _______
A. CPIS level + clinical criteria
B. Clinical criteria alone

68. • Clinical criteria ALONE

69. PPAP