Hospital Acquired Pneumonia (Adult) – Treatment
Infections, Respiratory
Context
- Hospital Acquired Pneumonia (HAP) = pneumonia acquired after >48 hours of hospitalization.
- Increased risk of:
- Staphylococcus aureus, Pseudomonas aeruginosa, enteric gram-negative bacilli.
- Consider sepsis.
- For COVID-19 see Covid 19: Clinicians.
Recommended Treatment
- Pathogen Identification:
- Allows adjustment to directed therapy.
- Sputum culture and gram stain.
- Blood cultures.
- Consider viral and atypical bacteria swab.
- Consider urinary antigen testing for pneumoniae.
- Allows adjustment to directed therapy.
- General treatment:
- Maintain oxygen SpO2 > 92% (if at risk for hypercapnia then SpO2 > 88%).
- IV fluids – concern of early sepsis/dehydration.
- Acetaminophen.
- Empiric Antibiotics:
- Spectrum App
- Be aware of local HAP pathogen distribution and resistance patterns.
- Treatment length is typically 7 days.
- MRSA Risk factors:
- IV antibiotics within last 90 days.
- Hospitalization where >20% of aureus is MRSA or prevalence is unknown.
- Pseudomonas Risk factors:
- IV antibiotics within last 90 days.
- Structural lung disease increasing the risk of gram-negative infection (eg. bronchiectasis).
- Gram negative bacilli predominant gram stain.
- High Mortality Risk factors:
- Septic shock.
- Ventilator required.
- No Pseudomonas or high mortality risk factors:
- Piperacillin-tazobactam 4.5g IV every 6 hours or,
- Cefepime 2g IV every 8 hours or,
- Levofloxacin 750mg IV daily or,
- Imipenem 500mg IV every 6 hours -OR- Meropenem 1g IV every 8 hours.
- Pseudomonas Risk – Use two antibiotics of different classes
- One of:
- Piperacillin-tazobactam 4.5g IV every 6 hours.
- Cefepime 2g IV every 8 hours -OR- Ceftazidime 2g IV every 8 hours.
- Imipenem 500mg IV every 6 hours -OR- Meropenem 1g IV every 8 hours.
- Aztreonam 2g IV every 8 hours.
- AND one of:
- Levofloxacin 750mg IV daily -OR- Ciprofloxacin 400mg IV every 8 hours.
- Amikacin 15–20 mg/kg IV daily -OR- Gentamicin 5–7 mg/kg IV daily -OR- Tobramycin 5–7 mg/kg IV daily.
- One of:
- MRSA Risk – ADD one of:
- Linezolid 600mg IV every 12 hours.
- Vancomycin:
- Loading dose:
- 25-30 mg/kg IV single dose (based on actual body weight; no maximum dose).
- Maintenance dose:
- 15 mg/kg IV dose q8-12 hours (based on actual body weight, maximum of 2 g/dose).
- For doses >500 mg – round to nearest 250 mg.
- Loading dose:
- High Mortality Risk
- Apply both Pseudomonas Risk and MRSA Risk regimens.
Criteria For Hospital Admission
- Patients with HAP who are not already admitted should be readmitted to receive intravenous antibiotics.
Criteria For Close Observation And/or Consult
- Patients with suspected sepsis, and those requiring vasopressors or ventilation should be admitted to the ICU.
- Consider transport when a higher level of care than your center provides may be required.
Quality Of Evidence?
High
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
Moderate
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
Low
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Justification
Main source is the 2016 guidelines by the Infectious Diseases Society of America and the American Thoracic Society on hospital and ventilator acquired pneumonia – most recommendations they make are based on low quality evidence.
Related Information
Reference List
Relevant Resources
RESOURCE AUTHOR(S)
DISCLAIMER
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Aug 31, 2020
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