This post is written by a guest writer, Jeff Pearson, PharmD. 

2019 UPDATE: The new CAP guidelines have been published! See our more recent post for more up-to-date information on community-acquired pneumonia treatment.

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In 2016, the Infectious Diseases Society of America (IDSA) published updated guidelines for the treatment of hospital-acquired pneumonia (HAP) & ventilator-associated pneumonia (VAP).

The plan was to release new community-acquired pneumonia (CAP) guidelines shortly thereafter.

Those CAP guidelines have now been pushed back to be tentatively published in summer 2018.

This post is meant to cover some common misconceptions about the treatment of pneumonia and clinical pearls while we patiently await the release of the new guidelines.

Let’s start with the basics:

HCAP & CAP – those presenting to the hospital with pneumonia
HAP & VAP – those that developed pneumonia >48 hours after admission to the hospital or mechanical ventilation, respectively.

But I thought the term HCAP was gone…

While the 2016 guidelines no longer address HCAP, HCAP as an entity has not disappeared (despite what some may tell you). It will likely be discussed in the as-of-yet unreleased CAP guidelines. But in the meantime, feel free to use the algorithm presented above for guidance.

Previous guidelines from 2005 grouped HCAP in with HAP and VAP in terms of treatment. But since then, it’s been determined that not all HCAP patients require MRSA and Pseudomonas coverage. Many can be treated as typical CAP patients.

High-risk HCAP patients =

• multiple risk factors for multi-drug resistant organisms (see green-box above)
• require ICU admission to justify broad spectrum antibiotic treatment.

Treatment:

CAP/low risk HCAP
—–NO MRSA or Pseudomonas coverage
—–YES atypical pneumonia pathogens coverage (i.e. mycoplasma, legionella, chlamydia spp.)
Ex. Levofloxacin; ceftriaxone + azithromycin*

High-risk HCAP
—–YES MRSA and Pseudomonas coverage
—–YES atypical pneumonia pathogens coverage (i.e. mycoplasma, legionella, chlamydia spp.)
Ex. Vancomycin + cefepime + azithromycin*

HAP
—–YES MRSA and Pseudomonas coverage
—–Consider double pseudomonal coverage if patient is hemodynamically unstable
—–NO atypical pneumonia pathogen coverage
Ex. Vancomycin + cefepime*

VAP
—–YES MRSA and Pseudomonas coverage
—–Consider double pseudomonal coverage if patient is hemodynamically unstable
—–NO atypical pneumonia pathogen coverage
Ex. Vancomycin + cefepime + tobramycin*

*These are example regimens. Please reference your own institution’s pneumonia guidelines for additional information.

 

Duration of Treatment = 7 days!!!

* This can likely be even shorter in cases of CAP.
** From the IDSA: “There exist situations in which a shorter or longer duration of antibiotics may be indicated, depending upon the rate of improvement of clinical, radiologic, and laboratory parameters.” ²

TAKE-HOME POINTS:

• HCAP is still an entity – but it has been separated from HAP
• CAP and HCAP – pneumonia <48 hours into a hospital stay
  HAP and VAP – pneumonia >48 hours into a hospital stay
• CAP and low risk HCAP – NO need for MRSA and Pseudomonas coverage
  High risk HCAP, HAP, and VAP – DO need MRSA and Pseudomonas coverage
• Duration of treatment = 7 days

 

2019 UPDATE: The new CAP guidelines have been published! See our more recent post for more up-to-date information on community-acquired pneumonia treatment.

References:

1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007; 44:S27-S72
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; 63(5):e61-e111
3. Dinh A, Ropers J, Davido B, et al. Effectiveness of three days of beta-lactam antibiotics for hospitalized community-acquired pneumonia: a randomized non-inferiority double-blind trial [abstract]. ECCMID Madrid, Spain, April 22, 2018.

Guest author: Jeff Pearson is a senior pharmacist in infectious diseases at Brigham and Women’s Hospital in Boston, where he serves as the point person for the hospital’s antimicrobial stewardship program. In addition to precepting Brigham pharmacy residents throughout the year, he also precepts Northeastern University and MCPHS University pharmacy students. Dr. Pearson received his Doctor of Pharmacy from Northeastern University in 2014. He completed his PGY-1 residency at Mount Auburn Hospital and PGY-2 residency in infectious diseases at Beth Israel Deaconess Medical Center.  He can be found on Twitter @jeffpears0n.

Peer-reviewed by Milana Bogorodskaya, MD