Table 33-8.
Guidelines for Empirical Antibiotic Treatment of Nosocomial Pneumonia*
| Setting | Core Pathogens | Antimicrobial Choices |
|---|---|---|
| 2 to 5 Days in Hospital | ||
| Mild to moderate pneumonia† Severe pneumonia “low-risk”† |
Enterobacteriaceae Streptococcus pneumoniae Haemophilus influenzae Methicillin-sensitive Staphylococcus aureus |
β-Lactam/β-lactamase inhibitor‡or ceftriaxone or fluoroquinolone§ All ± an aminoglycoside |
| ≥5 Days in Hospital | ||
| Mild to moderate pneumonia | As above | As above |
| ≥5 Days in Hospital | ||
| Severe HAP “low risk” |
Pseudomonas aeruginosa Enterobacter spp. Acinetobacter spp. |
Carbapenem or β-lactam/βl-lactamase inhibitor†or cefepime |
| All plus amikacin or fluoroquinolone§ | ||
| ≥2 Days in Hospital | ||
| Severe HAP “high risk” | As above | As above |
| Special Circumstances19, 58 | ||
| Recent abdominal surgery or witnessed aspiration | Anaerobes | As per Table 33-9 |
| Other sites of infection with MRSA or prior use of antistaphylococcal antibiotics | MRSA | As per Table 33-9 |
| Prolonged ICU stay or prior use of broad-spectrum antibiotics or structural lung disease (cystic fibrosis, bronchiectasis) | P. aeruginosa | As per Table 33-9 |
| Endemicity within facility and either impaired cell-mediated immunity or failure to respond to antibiotics | Legionella | As per Table 33-9 |
This protocol does not address the treatment of neutropenic or HIV-infected persons.
Severe pneumonia requiring care in an ICU is characterized by rapid radiographic progression, multilobar disease, or cavitation. All other cases of nosocomial pneumonia are considered mild to moderate.
HAP, hospital-acquired pneumonia; ICU, intensive care unit; MRSA, methicillin-resistant Staphylococcus aureus.
High-risk criteria include age older than 65 years, pancreatitis, chronic obstructive pulmonary disease, central nervous system dysfunction (stroke, drug overdose, coma, status epilepticus), congestive heart failure, malnutrition, diabetes mellitus, endotracheal intubation, renal failure, complicated thoracoabdominal surgery, and alcoholism. All other patients are considered to be at low risk.
Antimicrobial treatment should also be sufficient to cover core pathogens.
Ticarcillin-clavulanate and piperacillin-tazobactam are the preferred β-lactam/β-lactamase inhibitors for the treatment of nosocomial pneumonia. Ampicillin-sulbactam lacks adequate activity against many nosocomial enteric gram-negative bacilli.
Levofloxacin (IV or PO), gatifloxacin (IV or PO), moxifloxacin (IV or PO), or gemifloxacin (PO only) are preferred for Streptococcus pneumoniae. When used for severe HAP, levofloxacin should be dosed at 750 mg IV daily. Ciprofloxacin has the best in vitro activity against Pseudomonas aeruginosa.
Modified from American Thoracic Society: Hospital-acquired pneumonia in adults: Diagnosis assessment of severity, initial antimicrobial therapy, and preventative strategies. Am J Respir Crit Care Med 153:1711–1725, 1995.