Hospital Acquired Pneumonia (HAP) & Ventilator Associated Pneumonia (VAP)

Definitions

Hospital Acquired Pneumonia (HAP): pneumonia that occurs >48 after hospital admission, which was not incubating at the time of admission.
Ventilator Associated Pneumonia (VAP): pneumonia that arises greater than 48-72 hour after endotracheal intubation.

Choice of Antimicrobials

Indication for Therapy	Usual Causative Organisms	Antibiotic Regimens
Early or Late onset HAP or VAP No previous antibiotics in last 3 months No immunosuppressive disease No bronchiectasis Not intubated Hemodynamically stable	Streptococcus pneumonia Haemophilus influenza Methicillin-sensitive Staphylococcus aureus (MSSA) Enteric gram-negative bacilli (E. coli, K. pneumoniae, Enterobacter spp., Proteus spp., Serratia marcescens, Pseudomonas) Note: Pseudomonas is an infrequent cause of pneumonia in non-critical care areas at NH	cefTRIAXone 1g IV q24h
β-lactam allergy (anaphylaxis): moxifloxacin 400 mg IV q24h
HAP or VAP Prolonged hospital stay Immunosuppressive disease or therapy Hemodynamically unstable Previous antibiotics in last 3 months Bronchiectasis Intubated	Pathogens listed above plus the following pathogens that have the potential for multi-drug resistance: Pseudomonas aeruginosa Klebsiella pneumoniae Acinetobacter spp.	piperacillin-tazobactam 3.375 g IV q6h
β-lactam allergy (non-anaphylaxis): meropenem 1 g IV q8h
β-lactam allergy (anaphylaxis): Consider ID consult + vancomycin 15 mg/kg IV q12h + ciprofloxacin 400 mg IV q12h +/- tobramycin (see dosing guidelines)
HAP or VAP with MRSA suspected	Methicillin-resistant Staphylococcus aureus (MRSA) Risk factors include: MRSA colonization Head trauma Diabetes Hospitalization in ICU	Add vancomycin 20 mg/kg IV x 1 dose, then 15 mg/kg IV q12h

Early or Late onset HAP or VAP

No previous antibiotics in last 3 months
No immunosuppressive disease
No bronchiectasis
Not intubated

Hemodynamically stable

Streptococcus pneumonia

Haemophilus influenza
Methicillin-sensitive Staphylococcus aureus (MSSA)

Enteric gram-negative bacilli (E. coli, K. pneumoniae, Enterobacter spp., Proteus spp., Serratia marcescens, Pseudomonas)

Note: Pseudomonas is an infrequent cause of pneumonia in non-critical care areas at NH

cefTRIAXone 1g IV q24h

β-lactam allergy (anaphylaxis):

moxifloxacin 400 mg IV q24h

HAP or VAP

Prolonged hospital stay
Immunosuppressive disease or therapy
Hemodynamically unstable
Previous antibiotics in last 3 months
Bronchiectasis
Intubated

Pathogens listed above plus the following pathogens that have the potential for multi-drug resistance:

Pseudomonas aeruginosa

Klebsiella pneumoniae

Acinetobacter spp.

piperacillin-tazobactam 3.375 g IV q6h

β-lactam allergy (non-anaphylaxis):

meropenem 1 g IV q8h

β-lactam allergy (anaphylaxis):

Consider ID consult

vancomycin 15 mg/kg IV q12h

ciprofloxacin 400 mg IV q12h

+/-

tobramycin (see dosing guidelines)

HAP or VAP with MRSA suspected

Methicillin-resistant Staphylococcus aureus (MRSA)

Risk factors include:

MRSA colonization
Head trauma
Diabetes
Hospitalization in ICU

Add vancomycin 20 mg/kg IV x 1 dose, then 15 mg/kg IV q12h

Duration of Therapy

Patients initially treated with appropriate antibiotics typically require only 7-8 days of total therapy, except for P. aeruginosa and S. aureus pneumonia which may require a longer duration of treatment.

Combination regimens of a β-lactam and aminoglycoside to treat P. aeruginosa infections are not routinely recommended due to the lack of documented clear benefit. Combination therapy should be considered in specific patient circumstances such as previous infection with multi-drug resistant P. aeruginosa, febrile neutropenia, etc.

References

American Thoracic Society/Infectious Diseases Society of America. 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.
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;90:2588-98.
Hilf M, Yu VL, Sharp J et al. Antibiotic therapy for Pseudomonas aeruginosa bacteremia: outcome correlations in a prospective study of 200 patients. Am J Med. 1989;87:540-6.
Rotstein C, Evans G, Born A, et al. Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Can J Infect Dis Med Microbiol. 2008;19(1):19-53.
Anitbiotic Treatment Strategies for Community-Acquired Pneumonia in Adults. NEJM. 2015; 372:1312-1323.