Nosocomial Pneumonia Pathway for
Adults
Purpose:
To
provide a framework for the initial evaluation and management of the
immunocompetent, adult patient with bacterial causes of HAP, VAP, or HCAP based
on recent literature and guidelines. Delays in the initiation of appropriate
antibiotic therapy can increase mortality, and therapy should not be postponed
for the purpose of performing diagnostic studies in patients who are clinically
unstable.
Definitions:
Hospital Acquired Pneumonia (HAP) is defined as pneumonia that
occurs 48 hours or more after admission, which was not incubating at the time
of admission.
Ventilator Acquired Pneumonia (VAP) is defined as pneumonia that
arises more than 48–72 hours after endotracheal intubation.
Healthcare Associated Pneumonia (HCAP) includes pneumonia within 48
hours of hospital admission in any patient who was hospitalized in an acute
care hospital for two or more days within 90 days of the infection; resided in
a nursing home or long-term care facility; received recent intravenous
antibiotic therapy, chemotherapy, or wound care within the past 30 days of the
current infection; or attended a hospital or hemodialysis clinic.
Diagnosis:
The clinical diagnosis of HAP, VAP and HCAP can be made if
the patient has a new radiographic infiltrate PLUS at least two of the
following: fever > 38°C, leukocytosis or leucopenia, or
purulent secretions. Etiologic diagnosis
generally requires a lower respiratory tract culture, but rarely may be made
from blood or pleural fluid cultures.
Management:
All
patients with suspected HAP/VAP/HCAP should have a lower respiratory tract
sample and blood sent for culture, and patients with HAP and HCAP should have
sputum samples sent whenever possible before the administration of antibiotic
therapy. Extrapulmonary infection should be excluded as part of the evaluation
Unless
there is low clinical suspicion for lower respiratory tract infection, empiric
antibiotics should be initiated
Antibiotic selection:
The key
decision in initial empiric therapy is whether the patient has risk factors for
multidrug resistant (MDR) organisms (see above risk factors for MDR organisms
table).
See Antibiotic
Protocol for Nosocomial Pneumonia Empiric Therapy
Continuation of Therapy:
Broad-spectrum
empiric antibiotic therapy should be accompanied by a commitment to de-escalate
antibiotics, on the basis of serial clinical and microbiologic data, to limit
the emergence of resistance in the hospital.
All
patients with HAP, VAP and HCAP should initially receive therapy intravenously,
but conversion to oral/enteral therapy may be possible in certain responding
patients. Clinical improvement usually becomes apparent after the first 48–72
hours of therapy, and therefore, the selected antimicrobial regimen should not
be changed during this time unless progressive deterioration is noted or
initial microbiologic studies so dictate. Clinical parameters including the
white blood cell count and measures of oxygenation and core temperature have
been used in several studies to define the normal pattern of resolution of HAP.
The responding patient should have de-escalation of antibiotics, narrowing
therapy to the most focused regimen possible on the basis of culture data.
The
nonresponding patient should be evaluated for noninfectious mimics of
pneumonia, unsuspected or drug-resistant organisms, extrapulmonary sites of
infection, and complications of pneumonia and its therapy. Diagnostic testing
should be directed to whichever of these causes is likely.
Efforts
to reduce the duration of therapy are justified by studies of the natural
history of the response to therapy. Data support the premise that most patients
with VAP, who receive appropriate antimicrobial therapy, have a good clinical
response within the first 6 days. Prolonged therapy simply leads to
colonization with antibiotic resistant bacteria, which may precede a recurrent episode
of VAP.
Algorithm:
Antibiotic
Protocol for Adult Nosocomial Pneumonia Empiric Therapy
This pathway is to be used in adult (>18 yo),
immunocompetent patients only. A consult
from the Immunocompromised ID group is recommended when dealing with
hematopoetic stem cell or solid organ transplant patients. All dosages are based on normal renal and
hepatic function.
A. No known Risk Factors for
Multidrug-Resistant (MDR; see table below) Pathogens and Early Onset Disease
(< 5 d of hospital admission)
Ceftriaxone
1 gram (2 grams if > 80 kg) IV qday OR
Moxifloxacin*
400 mg PO/IV qday OR
Ampicillin/sulbactam
1.5 grams (3 grams if > 80 kg) IV q6h
B. Known Risk Factors for MDR Pathogens (see
table below) or
Late Onset Disease (≥ 5 d of
hospital admission)
Vancomycin 15 mg/kg q12h** OR
Linezolid 600 mg IV q12h
PLUS
Cefepime
2 grams IV q8h OR
Piperacillin/tazobactam
4.5 grams IV q6h OR
Imipenem
500 mg q6h
Penicillin allergy: aztreonam 2 grams IV q6h plus
clindamycin 900 mg IV q8h
PLUS***
Gentamicin
5-7 mg/kg IV qday**** OR
Tobramycin
5-7 mg/kg IV qday**** OR
Ciprofloxacin*
400 mg IV q8h
*Not recommended for use during
pregnancy.
**Trough levels for vancomycin
should be approximately 15 mg/L – Consult the pharmacist for pharmacokinetic
evaluation.
*** If Legionella is suspected, use
an aminoglycoside plus azithromycin 500 mg IV qday.
****Trough level for gentamicin and
tobramycin once-daily dosing should be 0 mg/L – Consult the pharmacist for
pharmacokinetic evaluation.
RISK FACTORS FOR
MULTIDRUG-RESISTANT ORGANISMS •
Antimicrobial therapy in preceding 90 d •
Current hospitalization of 5 d or more •
High frequency of antibiotic resistance in the community or in the specific hospital unit
(antibiogram can be found on the intranet) •
Presence of risk factors for HCAP: Hospitalization
for 2 d or more in the preceding 90 d Residence
in a nursing home or extended care facility Home
infusion therapy (including antibiotics) Chronic
dialysis within 30 d Home
wound care Family member with multidrug-resistant pathogen • Immunosuppressive disease
and/or therapy
