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) Early onset (<5 days)
Hospital-Acquired Pneumonia Late onset (>5 days) 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 5-7 days
5-7 days
a
c
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 ± tobramycin
7 days
e
7 days
e
7 days
e
7 days
e
Alternatives: cefepime + f,g 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 Five days for patients who defervesce within 72 hours and no more than one CAP-associated sign of clinical instability before discontinuation. CAP-associated signs of clinical stability (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. 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. American Thoracic Society. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171: 388-416. 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.
Revised: 3/19/2015
EMPIRIC TREATMENT OF BACTERIAL PNEUMONIA EMPIRIC TREATMENT ALGORITHM FOR HEALTHCARE-ASSOCIATED PNUEMONIA 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: 3/19/2015