Guideline sources The following summarized guidelines for the management of hospital-acquired pneumonia (HAP) are prepared by our editorial team based on guidelines from the European Society of Intensive Care Medicine (ESICM/ALAT/ERS/ESCMID 2017), the Infectious Diseases Society of America (IDSA/ATS 2016), and the Infectious Diseases Society of America (IDSA 2011). 1 2 3 4 4 5 6 7 Definition HAP (nosocomial pneumonia) is a lower respiratory infection occurring in patients at least 48 hours after admission to the hospital, or within 14 days after discharge from the hospital. 4 Epidemiology The three main infection routes include inhalation (most common), aspiration and hematogenous dissemination (rare). HAP is most frequently caused by S. aureus (especially, methicillin-resistant S. aureus), Pseudomonas species (especially P. aeruginosa), Acinetobacter species, E. coli, and Klebsiella species (including ESBL-producing and extensively drug-resistant Enterobacteriaceae). Other pathogens include S. maltophilia, Chryseobacterium species, E. meningoseptica. 6 Pathophysiology The incidence of HAP (HAP) in the United States is estimated at 363 per 100,000 patient-days. 5 Disease course https://web.pathway.md/diseases/recnrmysH538ONOB7 1/6 6/24/23, 12:45 PM Hospital-acquired pneumonia Pathway Clinical manifestations of HAP are similar to community-acquired pneumonia. Typical pneumonia is characterized by severe malaise, fever, chills, productive cough with purulent sputum (yellow- greenish), dyspnea, and pleuritic chest pain associated with rales and increased tactile fremitus. Atypical HAP presents with extrapulmonary manifestations (eg. myalgia, nervous system impairment, and gastrointestinal symptoms). 4 Prognosis and risk of recurrence Prognosis of HAP is highly dependent on risk factors and comorbidities. However, multidrug- resistant HAP is associated with higher mortality. 7 Guidelines 1. Medical management Initiation of treatment: use clinical criteria alone to decide whether or not to initiate antibiotic therapy in patients with suspected HAP. B Show 2 more Empiric antibiotic therapy, general principles: As per ALAT/ESCMID/ESICM/ERS 2017 guidelines, consider initiating narrow-spectrum antibiotics (ertapenem, ceftriaxone, cefotaxime, moxifloxacin, or levofloxacin) in patients with suspected low risk of resistance (without septic shock, no other risk factors for multidrug- resistant bacteria, and not in hospitals with a high background rate of resistant pathogens) and early-onset HAP. C Show 2 more As per ATS/IDSA 2016 guidelines: Initiate antibiotics with activity against S. aureus, P. aeruginosa, and other Gram-negative bacilli for empiric treatment of patients with HAP. B Consider determining antibiotic dosing using pharmacokinetic and pharmacodynamic data, rather than the manufacturer's prescribing information, in patients with HAP. C Empiric antibiotic therapy (MSSA coverage): Consider administering antibiotics with activity against methicillin-sensitive S. aureus (piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem) for initial empiric treatment of patients with HAP with no risk factors for MRSA infection and not being at high risk of mortality. C Avoid using oxacillin, nafcillin, or cefazolin for empiric therapy if one of the above agents is administered. D Empiric antibiotic therapy, MRSA coverage: As per ATS/IDSA 2016 guidelines: Consider administering an antibiotic with activity against MRSA in patients with HAP at high risk of mortality or with one of the following risk factors for MRSA infection: https://web.pathway.md/diseases/recnrmysH538ONOB7 2/6 6/24/23, 12:45 PM Hospital-acquired pneumonia Pathway prior IV antibiotic use within 90 days hospitalization in a unit where > 20% of S. aureus isolates are methicillin-resistant hospitalization in a unit where the prevalence of MRSA is not known. C Administer vancomycin or linezolid in patients with HAP requiring empiric coverage for MRSA. B As per IDSA 2011 guidelines, consider administering a loading dose of 25-30 mg/kg (actual body weight) of vancomycin in patients with HAP with suspected MRSA infection, may be considered. Consider prolonging the infusion time to 2 hours and administering an H1RA before administration of the loading dose given the risk of red man syndrome and possible anaphylaxis associated with large doses of vancomycin. C Empiric antibiotic therapy (Pseudomonas coverage): Consider administering antibiotics from 2 different classes with activity against P. aeruginosa in patients with HAP at high risk of mortality or risk factors for Pseudomonas or other Gram- negative infection (such as prior IV antibiotic use within 90 days). C Do not use an aminoglycoside as the sole empiric antipseudomonal agent in patients with HAP. D Definitive antibiotic therapy (general principles): Tailor antibiotic therapy to the susceptibility data of the etiological pathogen once microbiological and clinical response data become available (usually day 3). E Consider continuing treatment with a single agent based on culture results if the initial treatment was a combination therapy, and consider maintaining definitive combination treatment based on sensitivities in patients with extensively drug-resistant (susceptible to only 1-2 classes of antibiotics)/pandrug-resistant (not susceptible to any antibiotics) nonfermenting Gram-negative bacteria and carbapenem-resistant Enterobacteriaceae isolates. C Definitive antibiotic therapy (MSSA): administer oxacillin, nafcillin, or cefazolin in patients with HAP due to MSSA. B Definitive antibiotic therapy, MRSA: As per ATS/IDSA 2016 guidelines, administer either vancomycin or linezolid in patients with HAP due to MRSA. B As per IDSA 2011 guidelines, administer IV vancomycin or PO/IV linezolid 600 mg BID B or PO/IV clindamycin 600 mg TID B , if the strain is susceptible, for 7-21 days depending on the extent of infection in patients with healthcare-associated pneumonia due to MRSA. B Show 4 more Definitive antibiotic therapy (Pseudomonas aeruginosa): decide on the choice of an antibiotic for definitive therapy based on the results of antimicrobial susceptibility testing in patients with HAP due to P. aeruginosa. B Show 3 more Definitive antibiotic therapy (ESBL-producing pathogens): decide on the choice of an antibiotic for definitive therapy based on the results of antimicrobial susceptibility testing and patient-specific factors in patients with HAP due to ESBL-producing Gram-negative bacilli. B https://web.pathway.md/diseases/recnrmysH538ONOB7 3/6 6/24/23, 12:45 PM Hospital-acquired pneumonia Pathway Definitive antibiotic therapy (carbapenem-resistant pathogens): Administer intravenous polymyxins (colistin or polymyxin B) in patients with HAP due to a carbapenem-resistant pathogen sensitive only to polymyxins. B Consider administering adjunctive inhaled colistin in patients with HAP due to a carbapenem- resistant pathogen sensitive only to polymyxins. C Definitive antibiotic therapy (Acinetobacter species): consider administering either a carbapenem or ampicillin/sulbactam, if the isolate is susceptible to these agents, as definitive antibiotic therapy in patients with HAP due to Acinetobacter species. C Show 4 more Duration of treatment: As per ERS 2017 guidelines, consider completing a 7-8-day course of antibiotic therapy in nonventilated patients with HAP without immunodeficiency, cystic fibrosis, empyema, lung abscess, cavitation, or necrotizing pneumonia and with a good clinical response to therapy, as well as in patients with nonfermenting Gram-negative pathogens, Acinetobacter species, and MRSA with a good clinical response. C Show 2 more As per IDSA 2016 guidelines, complete a 7-day course of antimicrobial therapy in patients with HAP. B Show 3 more 2. Inpatient care Serial clinical assessment: Obtain routine bedside clinical assessment with the following in patients with HAP receiving antibiotic therapy E : temperature monitoring measurement of tracheobronchial secretion volume culture and purulence assessment of tracheobronchial secretions evaluation for CXR resolution WBC count paO2/FiO assessment of 1 clinical scores, such as CPIS, ODIN, SOFA, SAPS II, and APACHE II. Serial laboratory assessment: do not obtain biomarkers (such as CRP, procalcitonin, copeptin, and mid-regional pro-atrial natriuretic peptide) routinely in addition to bedside clinical assessment to predict adverse outcomes and clinical response at 72-96 hours in patients with HAP receiving antibiotic therapy. D Show 2 more 3. Quality improvement https://web.pathway.md/diseases/recnrmysH538ONOB7 4/6 6/24/23, 12:45 PM Hospital-acquired pneumonia Pathway Local susceptibility assessments: ensure regular generation and dissemination of local antibiograms in all hospitals, ideally tailored to their HAP population, if possible. References 1. Catherine Liu, Arnold Bayer, Sara E Cosgrove et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus aureus Infections in Adults and Children. Clin Infect Dis. 2011 Feb 1;52 3):e18 55. Open 2. Kalil AC, Metersky ML, Klompas M et al. Management of Adults With Hospital-acquired and Ventilator- associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016 Sep 1;63 5):e61-e111. Open 3. Antoni Torres, Michael S Niederman, Jean Chastre et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia HAP /ventilator-associated pneumonia VAP of the European Respiratory Society ERS , European Society of Intensive Care Medicine ESICM , European Society of Clinical Microbiology and Infectious Diseases ESCMID and Asociaci n Latinoamericana del T rax ALAT . Eur Respir J. 2017 Sep 10;50 3 1700582. Open 4. Charles W Lanks, Ali I Musani, David W Hsia. Community-acquired Pneumonia and Hospital-acquired Pneumonia. 2019 May;103 3 487 501.2019 May;103 3 487 501. Open 5. Karen K Giuliano, Dian Baker, Barbara Quinn. The epidemiology of nonventilator hospital-acquired pneumonia in the United States. 2018 Mar;46 3 322 327.2018 Mar;46 3 322 327. Open 6. Shio-Shin Jean, Yin-Chun Chang, Wei-Cheng Lin et al. Epidemiology, Treatment, and Prevention of Nosocomial Bacterial Pneumonia. J Clin Med. 2020 Jan 19;9 1 275. Open 7. Renato Seligman, Luis Francisco Ramos-Lima, Vivian do Amaral Oliveira et al. Risk factors for infection with multidrug-resistant bacteria in non-ventilated patients with hospital-acquired pneumonia. May-Jun 2013;39 3 339 48.May-Jun 2013;39 3 339 48. Open 8. Karen K Giuliano, Dian Baker, Barbara Quinn. The epidemiology of nonventilator hospital-acquired pneumonia in the United States. Am J Infect Control. 2018 Mar;46 3 322 327. Open 9. Fei Qi, Guo-Xin Zhang, Dan-Yang She et al. Healthcare-associated Pneumonia: Clinical Features and Retrospective Analysis Over 10 Years. Chin Med J Engl). 2015 Oct 20;128 20 2707 13. Open 10. Shio-Shin Jean, Yin-Chun Chang, Wei-Cheng Lin et al. Epidemiology, Treatment, and Prevention of Nosocomial Bacterial Pneumonia. 2020 Jan 19;9 1 275.2020 Jan 19;9 1 275. Open 11. M B Drakulovic, A Torres, T T Bauer et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet. 1999 Nov 27;354 9193 1851 8. Open 12. Marc Leone, Lila Bouadma, B la d Bouhemad et al. Hospital-acquired pneumonia in ICU. Anaesth Crit Care Pain Med. 2018 Feb;37 1 83 98. Open 13. Antoine Roquilly, Bruno Francois, Olivier Huet et al. Interferon gamma-1b for the prevention of hospital- acquired pneumonia in critically ill patients: a phase 2, placebo-controlled randomized clinical trial. Intensive Care Med. 2023 Apr 18;1 15. Open https://web.pathway.md/diseases/recnrmysH538ONOB7 5/6 6/24/23, 12:45 PM Hospital-acquired pneumonia Pathway https://web.pathway.md/diseases/recnrmysH538ONOB7 6/6