Pneumonia 2017

EMPIRIC TREATMENT OF BACTERIAL PNEUMONIA Clinical Setting Community-Acquired Pneumonia (CAP) Inpatient non-ICU care Comm...

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EMPIRIC TREATMENT OF BACTERIAL PNEUMONIA Clinical Setting Community-Acquired Pneumonia (CAP) Inpatient non-ICU care Community-Acquired Pneumonia ICU care

Healthcare-Associated Pneumonia (HCAP) Hospital-Acquired Pneumonia (HAP) Mild-to-moderate disease

Hospital-Acquired Pneumonia Severe disease Ventilator-Associated Pneumonia (VAP) >48 hours after intubation Aspiration Pneumonia

Likely Pathogens S. pneumoniae, H. influenzae, M. catarrhalis, atypicals (Legionella spp., Mycoplasma pneumoniae, Chlamydophila pneumoniae)

a,b

Empiric Therapy First line: ceftriaxone + azithromycin

Alternatives: moxifloxacin First line: ceftriaxone + (azithromycin or moxifloxacin) ± d vancomycin

Usual Duration c 5 days

5 days

c

7 days

e

7 days

e

7 days

e

7 days

e

a

Alternatives: aztreonam + (azithromycin or moxifloxacin) ± d vancomycin

See algorithm on next page S. pneumoniae, H. influenzae, S. aureus (including MRSA), Enterobactericeae P. aeruginosa, Acinetobacter spp., S. aureus (including MRSA), Enterobacteriaceae

First line: ceftriaxone ± f,g vancomycin

Oropharyngeal flora

First line: ampicillin-sulbactam

Alternatives: moxifloxacin ± f,g vancomycin First line: piperacillin-tazobactam f,g + vancomycin Alternatives: cefepime + f,g h vancomycin ± tobramycin

Alternatives: moxifloxacin a

Antibiotic therapy should be tailored based on susceptibility results. If respiratory cultures negative, consider discontinuing antibiotics or deescalating to CAP therapy. b If the patient had a documented multidrug resistant organism in the last 90 days, consider previous isolate susceptibility results when selecting empiric therapy c Consider extending to 7 days if not meeting the following criteria: defervesce within 72 hours AND no more than one CAPassociated sign of clinical instability if different from baseline (temp ≤ 37.8°C, HR ≤ 100 beats/min, RR ≤ 24 breaths/min, SBP ≥ 90 mmHg, Arterial O2 sat ≥ 90% or pO2 ≤ 60 mmHg on room air) d Consider adding anti-MRSA coverage if post-influenza pneumonia e If no prompt resolution of symptoms (defined as improved PaO2/FiO2 ratio by 3-5 days of therapy), consider prolonging therapy to 10-14 days. f Consider linezolid if MRSA pneumonia highly suspected (e.g. necrotizing pneumonia, previous MRSA pneumonia) g If respiratory cultures negative for MRSA, consider discontinuing vancomycin or linezolid at 48-72 hours. h Consider dual antipseudomonal coverage if prior intravenous broad-spectrum antibiotic use in past 90 days, need ventilator support, have septic shock, or in units where >10% of gram-negative isolates are resistant to agent considered for monotherapy References 1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44: S27-72. 2. Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63: e61-111. 3. Chastre J, Wolff M, Fagon JY, et al. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults. JAMA 2003; 290:2588-98. 4. Kollef MH, Morrow LE, Baughman RP, et al. Health care-associated pneumonia (HCAP): a critical appraisal to improve identification, management, and outcomes – proceedings of the HCAP summit. Clin Infect Dis 2008; 46: S296-334. 5. Labelle AJ, Arnold H, Reichley RM, et al. A comparison of culture-positive and culture-negative health-care-associated pneumonia. Chest 2010; 137: 1330-7. 6. Maruyama T, Fujisawa T, Okuno M, et al. A new strategy for healthcare-associated pneumonia: a 2-year prospective multicenter cohort study using risk factors for multidrug-resistant pathogens to select initial therapy. Clin Infect Dis 2013; 57:1373-83. 7. Heyland DK, Dodek P, Muscedere J, et al. Randomized trial of combination versus monotherapy for the empiric treatment of suspected ventilator-associated pneumonia. Crit Care Med 2008; 36: 737-44.

Revised: 2/16/2017

EMPIRIC TREATMENT OF BACTERIAL PNEUMONIA EMPIRIC TREATMENT ALGORITHM FOR HEALTHCARE-ASSOCIATED PNEUMONIA BASED ON STRATIFICATION OF RISK FACTORS AND SEVERITY Please see previous page for additional details on antibiotic selections. Healthcare-Associated Pneumonia (HCAP) Pneumonia and presence of one of the following: » Hospitalization > 48 hours in past 90 days » Residence in nursing home or long-term care facility » Attendance at hospital or hemodialysis clinic in past 30 days » Home infusion therapy (including antibiotics) » Home wound care » Exposure to a family member infection with an MDR pathogen

+ Immunosuppression defined as any of the following: » ANC <1000 » Congenital immunodeficiency » Splenectomy » HIV infection » Hematologic malignancy » Immunosuppressant therapy » Systemic steroid therapy (>10 mg prednisolone equivalent per day for 2+ weeks)

» »

Severe pneumonia? Need for mechanical ventilation ICU admission

NO » » » »

# Poor functional status defined as dependence on others to perform any 3 of the following: » Feed (includes tube feeds) » Bathe » Get dressed » Use toilet or cleaning self after use » Transfer from bed to chair and back » Partially or completely incontinent

YES

Risk factors for MDR pathogens Hospitalization > 48 hours in past 90 days + Immunosuppression # Poor functional status Antibiotic therapy in past 180 days

» » » »

Risk factors for MDR pathogens Hospitalization > 48 hours in past 90 days + Immunosuppression # Poor functional status Antibiotic therapy in past 180 days

0-1 MDR risk factors

>2 MDR risk factors

0 MDR risk factors

>1 MDR risk factors

Treat for common CAP pathogens

Treat for MDR pathogens

Treat for common CAP pathogens

Treat for MDR pathogen

Ceftriaxone + Azithromycin

Antipseudomonal beta-lactam (e.g. piperacillin-tazobactam, cefepime)

Ceftriaxone + (Azithromycin or moxifloxacin)

(e.g. piperacillin-tazobactam, cefepime)

Alternative: moxifloxacin

+ Vancomycin ± Tobramycin

Antipseudomonal beta-lactam + Vancomycin ± Tobramycin

Empiric therapy should be tailored based on culture results and susceptibility If respiratory cultures negative for MRSA, consider discontinuing vancomycin or linezolid at 48-72 hours. If respiratory cultures negative, consider discontinuing antibiotics or deescalating to CAP therapy.

Revised: 2/16/2017