Hospital-acquired pneumonia (non COVID-19)
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Look out for this icon: for treatment options that are affected, or added, as a result of your patient's comorbidities.
before culture results: without risk factors for multidrug-resistant (MDR) pathogen
empiric antibiotic monotherapy
For the management of patients with suspected or confirmed COVID-19 pneumonia, see Coronavirus disease 2019 (COVID-19). Pneumonia due to COVID-19 is not covered in this topic.
Absence of the following risk factors: antibiotic therapy in the preceding 90 days; septic shock at the time of ventilator-associated pneumonia (VAP); acute respiratory distress syndrome preceding VAP; current admission to the hospital 5 or more days; acute renal replacement therapy prior to VAP onset; a high-quality Gram stain with gram-negative bacilli; structural lung disease; and mechanical intubation and ventilation.[1]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):e61-111. http://cid.oxfordjournals.org/content/63/5/e61.long http://www.ncbi.nlm.nih.gov/pubmed/27418577?tool=bestpractice.com
Empiric antibiotic regimens should always be adapted to local patterns of resistance; an antibiogram should be consulted.[74]Ibrahim EH, Ward S, Sherman G, et al. Experience with a clinical guideline for the treatment of ventilator-associated pneumonia. Crit Care Med. 2001 Jun;29(6):1109-15. http://www.ncbi.nlm.nih.gov/pubmed/11395584?tool=bestpractice.com
If a patient has no risk factors for MDR pathogens, the causative pathogen of the pneumonia is likely to be Streptococcus pneumoniae, Haemophilus influenzae, methicillin-sensitive Staphylococcus aureus (MSSA), or antibiotic-sensitive enteric gram-negative bacilli (e.g., Escherichia coli, Klebsiella pneumoniae, Enterobacter species, Proteus species, or Serratia marcescens).
Systemic fluoroquinolone antibiotics, such as levofloxaxin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[111]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10056716 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.
While fluoroquinolones are no longer licensed for the treatment of nosocomial pneumonia in Europe, they are still approved for this indication in the US and other countries, and guidelines still recommend their use.[1]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):e61-111. http://cid.oxfordjournals.org/content/63/5/e61.long http://www.ncbi.nlm.nih.gov/pubmed/27418577?tool=bestpractice.com Therefore, the use of fluoroquinolones is still recommended in this topic, although they should be used with caution.
Primary options
cefepime: 2 g intravenously every 8 hours
OR
ceftazidime sodium: 2 g intravenously every 8 hours
OR
imipenem/cilastatin: 500 mg intravenously every 6 hours
More imipenem/cilastatinDose refers to imipenem component only.
OR
meropenem: 1 g intravenously every 8 hours
OR
levofloxacin: 750 mg intravenously every 24 hours
OR
piperacillin/tazobactam: 4.5 g intravenously every 6 hours; or 3.375 g intravenously every 4 hours
More piperacillin/tazobactam4.5 g dose consists of 4 g piperacillin plus 0.5 g tazobactam; 3.375 g dose consists of 3 g piperacillin plus 0.375 g tazobactam.
These drug options and doses relate to a patient with no comorbidities.
Primary options
cefepime: 2 g intravenously every 8 hours
OR
ceftazidime sodium: 2 g intravenously every 8 hours
OR
imipenem/cilastatin: 500 mg intravenously every 6 hours
More imipenem/cilastatinDose refers to imipenem component only.
OR
meropenem: 1 g intravenously every 8 hours
OR
levofloxacin: 750 mg intravenously every 24 hours
OR
piperacillin/tazobactam: 4.5 g intravenously every 6 hours; or 3.375 g intravenously every 4 hours
More piperacillin/tazobactam4.5 g dose consists of 4 g piperacillin plus 0.5 g tazobactam; 3.375 g dose consists of 3 g piperacillin plus 0.375 g tazobactam.
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
cefepime
OR
ceftazidime sodium
OR
imipenem/cilastatin
OR
meropenem
OR
levofloxacin
OR
piperacillin/tazobactam
supportive care
Treatment recommended for ALL patients in selected patient group
Administer oxygen therapy as necessary. Monitor oxygen saturation and inspired oxygen concentration with the aim of maintaining SaO 2 above 92%.[77]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017 May 15;4(1):e000170. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531304 http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com [78]Barnett A, Beasley R, Buchan C, et al. Thoracic Society of Australia and New Zealand position statement on acute oxygen use in adults: 'swimming between the flags'. Respirology. 2022 Apr;27(4):262-76. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9303673 http://www.ncbi.nlm.nih.gov/pubmed/35178831?tool=bestpractice.com High concentrations of oxygen can safely be given in uncomplicated pneumonia. Oxygen therapy in patients with COPD that is complicated by ventilatory failure should be guided by repeated arterial blood gas measurements.[77]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017 May 15;4(1):e000170. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531304 http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com Patients with respiratory failure despite appropriate oxygen therapy require urgent airway management and possible intubation. For conscious patients with an intact airway and escalating oxygen requirements, high flow nasal cannula oxygen therapy or noninvasive ventilation can be considered.[79]Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015 Jun 4;372(23):2185-96. https://www.nejm.org/doi/10.1056/NEJMoa1503326?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov http://www.ncbi.nlm.nih.gov/pubmed/25981908?tool=bestpractice.com [80]Qaseem A, Etxeandia-Ikobaltzeta I, Fitterman N, et al. Appropriate use of high-flow nasal oxygen in hospitalized patients for initial or postextubation management of acute respiratory failure: a clinical guideline from the American College of Physicians. Ann Intern Med. 2021 Jul;174(7):977-84. https://www.acpjournals.org/doi/full/10.7326/M20-7533?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/33900796?tool=bestpractice.com [81]Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017 Aug;50(2):1602426. https://publications.ersnet.org/content/erj?view=long&pmid=28860265 http://www.ncbi.nlm.nih.gov/pubmed/28860265?tool=bestpractice.com See Acute respiratory failure.
Assess volume status, paying particular attention to signs of volume depletion. Administer intravenous fluids if as needed according to local protocols, and give nutritional support in prolonged illness.
before culture results: with risk factors for multidrug-resistant (MDR) pathogen, including Pseudomonas and MRSA
empiric antibiotic combination therapy
For the management of patients with suspected or confirmed COVID-19 pneumonia, see Coronavirus disease 2019 (COVID-19). Pneumonia due to COVID-19 is not covered in this topic.
Presence of any of the following risk factors: antibiotic therapy in the preceding 90 days; septic shock at the time of ventilator-associated pneumonia (VAP); acute respiratory distress syndrome preceding VAP; current admission to the hospital 5 or more days; acute renal replacement therapy prior to VAP onset; a high-quality Gram stain with gram-negative bacilli; structural lung disease; mechanical intubation and ventilation.[1]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):e61-111. http://cid.oxfordjournals.org/content/63/5/e61.long http://www.ncbi.nlm.nih.gov/pubmed/27418577?tool=bestpractice.com
Empiric antibiotic regimens should always be adapted to local patterns of resistance; an antibiogram should be consulted.[74]Ibrahim EH, Ward S, Sherman G, et al. Experience with a clinical guideline for the treatment of ventilator-associated pneumonia. Crit Care Med. 2001 Jun;29(6):1109-15. http://www.ncbi.nlm.nih.gov/pubmed/11395584?tool=bestpractice.com
If a patient does have risk factors for MDR pathogens, the causative pathogen is likely to be Pseudomonas aeruginosa, Klebsiella pneumoniae (extended-spectrum beta-lactamase strain), Acinetobacter species, MRSA, or Legionella pneumophila. HAP/VAP due to one of these pathogens has been associated with an increased mortality.[85]Kett DH, Cano E, Quartin AA, et al. Implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care: an observational, multicentre cohort study. Lancet Infect Dis. 2011 Mar;11(3):181-9. http://www.ncbi.nlm.nih.gov/pubmed/21256086?tool=bestpractice.com
Pseudomonas should be covered with regimens containing various combinations of antipseudomonal beta-lactams, carbapenems, fluoroquinolones, and aminoglycosides. Imipenem/cilastatin or meropenem (carbapenem antibiotics) could be used, but ertapenem should not, as it does not cover P aeruginosa and is only approved for community-acquired pneumonia. Empiric treatment with a carbapenem has been associated with lower short-term mortality than treatment with no-carbapenems mainly in patients with VAP; but also with increased resistance, making it harder to escalate an antimicrobial regimen if needed.[86]Howatt M, Klompas M, Kalil AC, et al. Carbapenem antibiotics for the empiric treatment of nosocomial pneumonia: a systematic review and meta-analysis. Chest. 2021 Mar;159(3):1041-54. http://www.ncbi.nlm.nih.gov/pubmed/33393468?tool=bestpractice.com Ceftazidime/avibactam is another beta-lactam option and is best suited for multidrug-resistant gram-negative pathogens.[87]Torres A, Zhong N, Pachl J, et al. Ceftazidime-avibactam versus meropenem in nosocomial pneumonia, including ventilator-associated pneumonia (REPROVE): a randomised, double-blind, phase 3 non-inferiority trial. Lancet Infect Dis. 2018 Mar;18(3):285-95. http://www.ncbi.nlm.nih.gov/pubmed/29254862?tool=bestpractice.com Other approved antibiotics with P aeruginosa coverage for patients with HAP/VAP and multidrug-resistant gram-negative pathogen infection include cefiderocol (a novel siderophore cephalosporin), and the combination antibiotics imipenem/cilastatin/relebactam (a carbapenem with a potent beta-lactamase inhibitor) and ceftolozane/tazobactam (a novel beta-lactam/beta-lactamase inhibitor).
To cover for MRSA, linezolid or vancomycin (or, alternately, telavancin) should be added (i.e., a total of 3 antibiotics are given).
If HAP is diagnosed after antibiotics have been used recently or while a patient is receiving antibiotics for a different infection, empiric therapy should involve drugs from a different class.[118]Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med. 2002 Apr 1;165(7):867-903. http://www.atsjournals.org/doi/full/10.1164/ajrccm.165.7.2105078#.UkWU9tKsjTo http://www.ncbi.nlm.nih.gov/pubmed/11934711?tool=bestpractice.com
Serum drug levels should be monitored with aminoglycosides and vancomycin to prevent serious adverse effects.
For patients with a beta-lactam allergy, consider local resistance patterns and risks/benefits of medication adverse effects, and use 2 of the following antibiotics: a fluoroquinolone, an aminoglycoside, or colistimethate.
Systemic fluoroquinolone antibiotics, such as ciprofloxacin or levofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[111]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10056716 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.
While fluoroquinolones are no longer licensed for the treatment of nosocomial pneumonia in Europe, they are still approved for this indication in the US and other countries, and guidelines still recommend their use.[1]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):e61-111. http://cid.oxfordjournals.org/content/63/5/e61.long http://www.ncbi.nlm.nih.gov/pubmed/27418577?tool=bestpractice.com Therefore, the use of fluoroquinolones is still recommended in this topic, although they should be used with caution.
Primary options
cefepime: 2 g intravenously every 8 hours
or
imipenem/cilastatin: 500 mg intravenously every 6 hours
More imipenem/cilastatinDose refers to imipenem component only.
or
meropenem: 1 g intravenously every 8 hours
or
piperacillin/tazobactam: 4.5 g intravenously every 6 hours; or 3.375 g intravenously every 4 hours
More piperacillin/tazobactam4.5 g dose consists of 4 g piperacillin plus 0.5 g tazobactam; 3.375 g dose consists of 3 g piperacillin plus 0.375 g tazobactam.
or
aztreonam: 2 g intravenously every 8 hours
or
ceftazidime/avibactam: 2.5 g intravenously every 8 hours
More ceftazidime/avibactamDose consists of 2 g of ceftazidime plus 0.5 g of avibactam.
or
cefiderocol: 2 g intravenously every 8 hours
or
ceftolozane/tazobactam: 3 g intravenously every 8 hours
More ceftolozane/tazobactamDose consists of 2 g of ceftolozane plus 1 g of tazobactam.
or
imipenem/cilastatin/relebactam: 1.25 g intravenously every 6 hours
More imipenem/cilastatin/relebactamDose consists of 0.5 g of imipenem plus 0.5 g of cilastatin plus 0.25 g of relebactam.
-- AND --
ciprofloxacin: 400 mg intravenously every 8 hours
or
levofloxacin: 750 mg intravenously every 24 hours
or
amikacin: 15-20 mg/kg intravenously every 24 hours
or
gentamicin: 5-7 mg/kg intravenously every 24 hours
or
tobramycin: 5-7 mg/kg intravenously every 24 hours
-- AND --
linezolid: 600 mg intravenously every 12 hours
or
vancomycin: 15 mg/kg intravenously every 12 hours
or
telavancin: 10 mg/kg intravenously every 24 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
cefepime: 2 g intravenously every 8 hours
or
imipenem/cilastatin: 500 mg intravenously every 6 hours
More imipenem/cilastatinDose refers to imipenem component only.
or
meropenem: 1 g intravenously every 8 hours
or
piperacillin/tazobactam: 4.5 g intravenously every 6 hours; or 3.375 g intravenously every 4 hours
More piperacillin/tazobactam4.5 g dose consists of 4 g piperacillin plus 0.5 g tazobactam; 3.375 g dose consists of 3 g piperacillin plus 0.375 g tazobactam.
or
aztreonam: 2 g intravenously every 8 hours
or
ceftazidime/avibactam: 2.5 g intravenously every 8 hours
More ceftazidime/avibactamDose consists of 2 g of ceftazidime plus 0.5 g of avibactam.
or
cefiderocol: 2 g intravenously every 8 hours
or
ceftolozane/tazobactam: 3 g intravenously every 8 hours
More ceftolozane/tazobactamDose consists of 2 g of ceftolozane plus 1 g of tazobactam.
or
imipenem/cilastatin/relebactam: 1.25 g intravenously every 6 hours
More imipenem/cilastatin/relebactamDose consists of 0.5 g of imipenem plus 0.5 g of cilastatin plus 0.25 g of relebactam.
-- AND --
ciprofloxacin: 400 mg intravenously every 8 hours
or
levofloxacin: 750 mg intravenously every 24 hours
or
amikacin: 15-20 mg/kg intravenously every 24 hours
or
gentamicin: 5-7 mg/kg intravenously every 24 hours
or
tobramycin: 5-7 mg/kg intravenously every 24 hours
-- AND --
linezolid: 600 mg intravenously every 12 hours
or
vancomycin: 15 mg/kg intravenously every 12 hours
or
telavancin: 10 mg/kg intravenously every 24 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
cefepime
or
imipenem/cilastatin
or
meropenem
or
piperacillin/tazobactam
or
aztreonam
or
ceftazidime/avibactam
or
cefiderocol
or
ceftolozane/tazobactam
or
imipenem/cilastatin/relebactam
-- AND --
ciprofloxacin
or
levofloxacin
or
amikacin
or
gentamicin
or
tobramycin
-- AND --
linezolid
or
vancomycin
or
telavancin
supportive care
Treatment recommended for ALL patients in selected patient group
Administer oxygen therapy as necessary. Monitor oxygen saturation and inspired oxygen concentration with the aim of maintaining SaO 2 above 92%.[77]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017 May 15;4(1):e000170. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531304 http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com [78]Barnett A, Beasley R, Buchan C, et al. Thoracic Society of Australia and New Zealand position statement on acute oxygen use in adults: 'swimming between the flags'. Respirology. 2022 Apr;27(4):262-76. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9303673 http://www.ncbi.nlm.nih.gov/pubmed/35178831?tool=bestpractice.com High concentrations of oxygen can safely be given in uncomplicated pneumonia. Oxygen therapy in patients with COPD that is complicated by ventilatory failure should be guided by repeated arterial blood gas measurements.[77]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017 May 15;4(1):e000170. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531304 http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com Patients with respiratory failure despite appropriate oxygen therapy require urgent airway management and possible intubation. For conscious patients with an intact airway and escalating oxygen requirements, high flow nasal cannula oxygen therapy or noninvasive ventilation can be considered.[79]Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015 Jun 4;372(23):2185-96. https://www.nejm.org/doi/10.1056/NEJMoa1503326?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov http://www.ncbi.nlm.nih.gov/pubmed/25981908?tool=bestpractice.com [80]Qaseem A, Etxeandia-Ikobaltzeta I, Fitterman N, et al. Appropriate use of high-flow nasal oxygen in hospitalized patients for initial or postextubation management of acute respiratory failure: a clinical guideline from the American College of Physicians. Ann Intern Med. 2021 Jul;174(7):977-84. https://www.acpjournals.org/doi/full/10.7326/M20-7533?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/33900796?tool=bestpractice.com [81]Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017 Aug;50(2):1602426. https://publications.ersnet.org/content/erj?view=long&pmid=28860265 http://www.ncbi.nlm.nih.gov/pubmed/28860265?tool=bestpractice.com See Acute respiratory failure.
Assess volume status, paying particular attention to signs of volume depletion. Administer intravenous fluids if as needed according to local protocols, and give nutritional support in prolonged illness.
after culture results: due to gram-negative pathogen
pathogen-directed antibiotic therapy
Once cultures return, antibiotics should be de-escalated accordingly; that is, treatment should be narrowed based on the sensitivities of what particular pathogen grew, or antimicrobials should be discontinued based on what did not grow.
Common gram-negative non-Pseudomonas organisms that can cause HAP include Acinetobacter, Klebsiella pneumoniae, and Serratia marcescens.
Monotherapy with a single antibiotic should be sufficient in many cases. However, 2 drugs in combination can be used if the infection is in a difficult area to penetrate, such as a lung abscess, an empyema, or an accompanying endocarditis.
For patients with a beta-lactam allergy, consider local resistance patterns and risks/benefits of medication adverse effects, and use 2 of the following antibiotics: a fluoroquinolone, an aminoglycoside, or colistimethate.
Systemic fluoroquinolone antibiotics, such as ciprofloxacin or levofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[111]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10056716 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.
While fluoroquinolones are no longer licensed for the treatment of nosocomial pneumonia in Europe, they are still approved for this indication in the US and other countries, and guidelines still recommend their use.[1]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):e61-111. http://cid.oxfordjournals.org/content/63/5/e61.long http://www.ncbi.nlm.nih.gov/pubmed/27418577?tool=bestpractice.com Therefore, the use of fluoroquinolones is still recommended in this topic, although they should be used with caution.
Treatment course: 7 days if patient is clinically stable and not infected with Acinetobacter; 14 days if infected with Acinetobacter, or not clinically/radiographically improving, or improving slowly.
Primary options
cefepime: 2 g intravenously every 8 hours
OR
ceftazidime sodium: 2 g intravenously every 8 hours
OR
imipenem/cilastatin: 500 mg intravenously every 6 hours
More imipenem/cilastatinDose refers to imipenem component only.
OR
meropenem: 1 g intravenously every 8 hours
OR
piperacillin/tazobactam: 4.5 g intravenously every 6 hours; or 3.375 g intravenously every 4 hours
More piperacillin/tazobactam4.5 g dose consists of 4 g piperacillin plus 0.5 g tazobactam; 3.375 g dose consists of 3 g piperacillin plus 0.375 g tazobactam.
OR
ciprofloxacin: 400 mg intravenously every 8 hours
OR
levofloxacin: 750 mg intravenously every 24 hours
OR
amikacin: 15-20 mg/kg intravenously every 24 hours
OR
gentamicin: 5-7 mg/kg intravenously every 24 hours
OR
tobramycin: 5-7 mg/kg intravenously every 24 hours
OR
colistimethate: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
cefepime: 2 g intravenously every 8 hours
OR
ceftazidime sodium: 2 g intravenously every 8 hours
OR
imipenem/cilastatin: 500 mg intravenously every 6 hours
More imipenem/cilastatinDose refers to imipenem component only.
OR
meropenem: 1 g intravenously every 8 hours
OR
piperacillin/tazobactam: 4.5 g intravenously every 6 hours; or 3.375 g intravenously every 4 hours
More piperacillin/tazobactam4.5 g dose consists of 4 g piperacillin plus 0.5 g tazobactam; 3.375 g dose consists of 3 g piperacillin plus 0.375 g tazobactam.
OR
ciprofloxacin: 400 mg intravenously every 8 hours
OR
levofloxacin: 750 mg intravenously every 24 hours
OR
amikacin: 15-20 mg/kg intravenously every 24 hours
OR
gentamicin: 5-7 mg/kg intravenously every 24 hours
OR
tobramycin: 5-7 mg/kg intravenously every 24 hours
OR
colistimethate: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
cefepime
OR
ceftazidime sodium
OR
imipenem/cilastatin
OR
meropenem
OR
piperacillin/tazobactam
OR
ciprofloxacin
OR
levofloxacin
OR
amikacin
OR
gentamicin
OR
tobramycin
OR
colistimethate
supportive care
Treatment recommended for ALL patients in selected patient group
Administer oxygen therapy as necessary. Monitor oxygen saturation and inspired oxygen concentration with the aim of maintaining SaO 2 above 92%.[77]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017 May 15;4(1):e000170. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531304 http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com [78]Barnett A, Beasley R, Buchan C, et al. Thoracic Society of Australia and New Zealand position statement on acute oxygen use in adults: 'swimming between the flags'. Respirology. 2022 Apr;27(4):262-76. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9303673 http://www.ncbi.nlm.nih.gov/pubmed/35178831?tool=bestpractice.com High concentrations of oxygen can safely be given in uncomplicated pneumonia. Oxygen therapy in patients with COPD complicated by ventilatory failure should be guided by repeated arterial blood gas measurements.[77]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017 May 15;4(1):e000170. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531304 http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com Patients with respiratory failure despite appropriate oxygen therapy require urgent airway management and possible intubation. For conscious patients with an intact airway and escalating oxygen requirements, high flow nasal cannula oxygen therapy or noninvasive ventilation can be considered.[79]Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015 Jun 4;372(23):2185-96. https://www.nejm.org/doi/10.1056/NEJMoa1503326?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov http://www.ncbi.nlm.nih.gov/pubmed/25981908?tool=bestpractice.com [80]Qaseem A, Etxeandia-Ikobaltzeta I, Fitterman N, et al. Appropriate use of high-flow nasal oxygen in hospitalized patients for initial or postextubation management of acute respiratory failure: a clinical guideline from the American College of Physicians. Ann Intern Med. 2021 Jul;174(7):977-84. https://www.acpjournals.org/doi/full/10.7326/M20-7533?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/33900796?tool=bestpractice.com [81]Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017 Aug;50(2):1602426. https://publications.ersnet.org/content/erj?view=long&pmid=28860265 http://www.ncbi.nlm.nih.gov/pubmed/28860265?tool=bestpractice.com See Acute respiratory failure.
Assess volume status, paying particular attention to signs of volume depletion. Administer intravenous fluids as needed, and give nutritional support in prolonged illness.
pathogen-directed antibiotic therapy
Once cultures return, antibiotics should be de-escalated accordingly; that is, treatment should be narrowed based on the sensitivities of what particular pathogen grew, or antimicrobials should be discontinued based on what did not grow.
Common gram-negative organisms that can cause HAP include Pseudomonas aeruginosa, Acinetobacter, Klebsiella pneumoniae, and Serratia marcescens.
If multidrug-resistant gram-negative pathogens are identified, then ceftazidime/avibactam may be tested and, if sensitive, may be used for HAP or ventilator-associated pneumonia (VAP) due to bacteria. A simpler agent should be used, if available, in order to prevent resistance to ceftazidime/avibactam. Other approved antibiotics with P aeruginosa coverage for patients with HAP/VAP and multidrug-resistant gram-negative pathogen infection include cefiderocol (a novel siderophore cephalosporin), and the combination antibiotics imipenem/cilastatin/relebactam (imipenem/cilastatin combined with a potent beta-lactamase inhibitor) and ceftolozane/tazobactam (a novel beta-lactam/beta-lactamase inhibitor).
Monotherapy with a single antibiotic should be sufficient in many cases. However, 2 drugs in combination can be used if the infection is in a difficult area to penetrate, such as a lung abscess, an empyema, or an accompanying endocarditis.
For patients with a beta-lactam allergy, consider local resistance patterns and risks/benefits of medication adverse effects, and use 2 of the following antibiotics: a fluoroquinolone, an aminoglycoside, or colistimethate.
Systemic fluoroquinolone antibiotics, such as ciprofloxacin or levofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[111]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10056716 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.
While fluoroquinolones are no longer licensed for the treatment of nosocomial pneumonia in Europe, they are still approved for this indication in the US and other countries, and guidelines still recommend their use.[1]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):e61-111. http://cid.oxfordjournals.org/content/63/5/e61.long http://www.ncbi.nlm.nih.gov/pubmed/27418577?tool=bestpractice.com Therefore, the use of fluoroquinolones is still recommended in this topic, although they should be used with caution.
Treatment course: 7 days if patient is clinically stable and not infected with Pseudomonas or Acinetobacter; 14 days if infected with Pseudomonas or Acinetobacter, or associated with sepsis or complications.
Primary options
cefepime: 2 g intravenously every 8 hours
or
ceftazidime sodium: 2 g intravenously every 8 hours
or
imipenem/cilastatin: 500 mg intravenously every 6 hours
More imipenem/cilastatinDose refers to imipenem component only.
or
meropenem: 1 g intravenously every 8 hours
or
piperacillin/tazobactam: 4.5 g intravenously every 6 hours; or 3.375 g intravenously every 4 hours
More piperacillin/tazobactam4.5 g dose consists of 4 g piperacillin plus 0.5 g tazobactam; 3.375 g dose consists of 3 g piperacillin plus 0.375 g tazobactam.
or
ceftazidime/avibactam: 2.5 g intravenously every 8 hours
More ceftazidime/avibactamDose consists of 2 g of ceftazidime plus 0.5 g of avibactam.
or
cefiderocol: 2 g intravenously every 8 hours
or
ceftolozane/tazobactam: 3 g intravenously every 8 hours
More ceftolozane/tazobactamDose consists of 2 g of ceftolozane plus 1 g of tazobactam.
or
imipenem/cilastatin/relebactam: 1.25 g intravenously every 6 hours
More imipenem/cilastatin/relebactamDose consists of 0.5 g of imipenem plus 0.5 g of cilastatin plus 0.25 g of relebactam.
-- AND --
ciprofloxacin: 400 mg intravenously every 8 hours
or
levofloxacin: 750 mg intravenously every 24 hours
or
amikacin: 15-20 mg/kg intravenously every 24 hours
or
gentamicin: 5-7 mg/kg intravenously every 24 hours
or
tobramycin: 5-7 mg/kg intravenously every 24 hours
or
colistimethate: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
cefepime: 2 g intravenously every 8 hours
or
ceftazidime sodium: 2 g intravenously every 8 hours
or
imipenem/cilastatin: 500 mg intravenously every 6 hours
More imipenem/cilastatinDose refers to imipenem component only.
or
meropenem: 1 g intravenously every 8 hours
or
piperacillin/tazobactam: 4.5 g intravenously every 6 hours; or 3.375 g intravenously every 4 hours
More piperacillin/tazobactam4.5 g dose consists of 4 g piperacillin plus 0.5 g tazobactam; 3.375 g dose consists of 3 g piperacillin plus 0.375 g tazobactam.
or
ceftazidime/avibactam: 2.5 g intravenously every 8 hours
More ceftazidime/avibactamDose consists of 2 g of ceftazidime plus 0.5 g of avibactam.
or
cefiderocol: 2 g intravenously every 8 hours
or
ceftolozane/tazobactam: 3 g intravenously every 8 hours
More ceftolozane/tazobactamDose consists of 2 g of ceftolozane plus 1 g of tazobactam.
or
imipenem/cilastatin/relebactam: 1.25 g intravenously every 6 hours
More imipenem/cilastatin/relebactamDose consists of 0.5 g of imipenem plus 0.5 g of cilastatin plus 0.25 g of relebactam.
-- AND --
ciprofloxacin: 400 mg intravenously every 8 hours
or
levofloxacin: 750 mg intravenously every 24 hours
or
amikacin: 15-20 mg/kg intravenously every 24 hours
or
gentamicin: 5-7 mg/kg intravenously every 24 hours
or
tobramycin: 5-7 mg/kg intravenously every 24 hours
or
colistimethate: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
cefepime
or
ceftazidime sodium
or
imipenem/cilastatin
or
meropenem
or
piperacillin/tazobactam
or
ceftazidime/avibactam
or
cefiderocol
or
ceftolozane/tazobactam
or
imipenem/cilastatin/relebactam
-- AND --
ciprofloxacin
or
levofloxacin
or
amikacin
or
gentamicin
or
tobramycin
or
colistimethate
supportive care
Treatment recommended for ALL patients in selected patient group
Administer oxygen therapy as necessary. Monitor oxygen saturation and inspired oxygen concentration with the aim of maintaining SaO 2 above 92%.[77]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017 May 15;4(1):e000170. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531304 http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com [78]Barnett A, Beasley R, Buchan C, et al. Thoracic Society of Australia and New Zealand position statement on acute oxygen use in adults: 'swimming between the flags'. Respirology. 2022 Apr;27(4):262-76. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9303673 http://www.ncbi.nlm.nih.gov/pubmed/35178831?tool=bestpractice.com High concentrations of oxygen can safely be given in uncomplicated pneumonia. Oxygen therapy in patients with COPD complicated by ventilatory failure should be guided by repeated arterial blood gas measurements.[77]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017 May 15;4(1):e000170. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531304 http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com Patients with respiratory failure despite appropriate oxygen therapy require urgent airway management and possible intubation. For conscious patients with an intact airway and escalating oxygen requirements, high flow nasal cannula oxygen therapy or noninvasive ventilation can be considered.[79]Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015 Jun 4;372(23):2185-96. https://www.nejm.org/doi/10.1056/NEJMoa1503326?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov http://www.ncbi.nlm.nih.gov/pubmed/25981908?tool=bestpractice.com [80]Qaseem A, Etxeandia-Ikobaltzeta I, Fitterman N, et al. Appropriate use of high-flow nasal oxygen in hospitalized patients for initial or postextubation management of acute respiratory failure: a clinical guideline from the American College of Physicians. Ann Intern Med. 2021 Jul;174(7):977-84. https://www.acpjournals.org/doi/full/10.7326/M20-7533?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/33900796?tool=bestpractice.com [81]Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017 Aug;50(2):1602426. https://publications.ersnet.org/content/erj?view=long&pmid=28860265 http://www.ncbi.nlm.nih.gov/pubmed/28860265?tool=bestpractice.com See Acute respiratory failure.
Assess volume status, paying particular attention to signs of volume depletion. Administer intravenous fluids as needed, and give nutritional support in prolonged illness.
pathogen-directed antibiotic therapy
If ESBL-producing Enterobacterales are the cause of HAP, then recommended first-line treatment is with a carbapenem antibiotic. Second-line treatment is with a fluoroquinolone.[103]Tamma PD, Aitken SL, Bonomo RA, et al. Infectious Diseases Society of America 2022 Guidance on the treatment of extended-spectrum β-lactamase producing Enterobacterales (ESBL-E), carbapenem-resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with difficult-to-treat resistance (DTR-P. aeruginosa). Clin Infect Dis. 2022 Aug 25;75(2):187-212. http://www.ncbi.nlm.nih.gov/pubmed/35439291?tool=bestpractice.com In practice, a third-line treatment is with a carbapenem/beta-lactamase inhibitor or cefiderocol. Ceftolozane/tazobactam also has activity against some ESBLs.
Systemic fluoroquinolone antibiotics, such as ciprofloxacin or levofloxacin or moxifloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[111]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10056716 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.
While fluoroquinolones are no longer licensed for the treatment of nosocomial pneumonia in Europe, they are still approved for this indication in the US and other countries, and guidelines still recommend their use.[1]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):e61-111. http://cid.oxfordjournals.org/content/63/5/e61.long http://www.ncbi.nlm.nih.gov/pubmed/27418577?tool=bestpractice.com Therefore, the use of fluoroquinolones is still recommended in this topic, although they should be used with caution.
Treatment course: 7 days if patient is clinically stable; 14 days if associated with sepsis or complications.
All of these drugs are antipseudomonal drugs, and may be used for such after checking sensitivities.
Primary options
imipenem/cilastatin: 500 mg intravenously every 6 hours
More imipenem/cilastatinDose refers to imipenem component only.
OR
meropenem: 1 g intravenously every 8 hours
OR
ceftazidime/avibactam: 2.5 g intravenously every 8 hours
More ceftazidime/avibactamDose consists of 2 g of ceftazidime plus 0.5 g of avibactam.
Secondary options
ciprofloxacin: 400 mg intravenously every 8 hours
OR
levofloxacin: 750 mg intravenously every 24 hours
OR
moxifloxacin: 400 mg intravenously every 24 hours
Tertiary options
cefiderocol: 2 g intravenously every 8 hours
OR
ceftolozane/tazobactam: 3 g intravenously every 8 hours
More ceftolozane/tazobactamDose consists of 2 g of ceftolozane plus 1 g of tazobactam.
OR
imipenem/cilastatin/relebactam: 1.25 g intravenously every 6 hours
More imipenem/cilastatin/relebactamDose consists of 0.5 g of imipenem plus 0.5 g of cilastatin plus 0.25 g of relebactam.
These drug options and doses relate to a patient with no comorbidities.
Primary options
imipenem/cilastatin: 500 mg intravenously every 6 hours
More imipenem/cilastatinDose refers to imipenem component only.
OR
meropenem: 1 g intravenously every 8 hours
OR
ceftazidime/avibactam: 2.5 g intravenously every 8 hours
More ceftazidime/avibactamDose consists of 2 g of ceftazidime plus 0.5 g of avibactam.
Secondary options
ciprofloxacin: 400 mg intravenously every 8 hours
OR
levofloxacin: 750 mg intravenously every 24 hours
OR
moxifloxacin: 400 mg intravenously every 24 hours
Tertiary options
cefiderocol: 2 g intravenously every 8 hours
OR
ceftolozane/tazobactam: 3 g intravenously every 8 hours
More ceftolozane/tazobactamDose consists of 2 g of ceftolozane plus 1 g of tazobactam.
OR
imipenem/cilastatin/relebactam: 1.25 g intravenously every 6 hours
More imipenem/cilastatin/relebactamDose consists of 0.5 g of imipenem plus 0.5 g of cilastatin plus 0.25 g of relebactam.
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
imipenem/cilastatin
OR
meropenem
OR
ceftazidime/avibactam
Secondary options
ciprofloxacin
OR
levofloxacin
OR
moxifloxacin
Tertiary options
cefiderocol
OR
ceftolozane/tazobactam
OR
imipenem/cilastatin/relebactam
supportive care
Treatment recommended for ALL patients in selected patient group
Administer oxygen therapy as necessary. Monitor oxygen saturation and inspired oxygen concentration with the aim of maintaining SaO 2 above 92%.[77]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017 May 15;4(1):e000170. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531304 http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com [78]Barnett A, Beasley R, Buchan C, et al. Thoracic Society of Australia and New Zealand position statement on acute oxygen use in adults: 'swimming between the flags'. Respirology. 2022 Apr;27(4):262-76. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9303673 http://www.ncbi.nlm.nih.gov/pubmed/35178831?tool=bestpractice.com High concentrations of oxygen can safely be given in uncomplicated pneumonia. Oxygen therapy in patients with COPD complicated by ventilatory failure should be guided by repeated arterial blood gas measurements.[77]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017 May 15;4(1):e000170. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531304 http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com Patients with respiratory failure despite appropriate oxygen therapy require urgent airway management and possible intubation. For conscious patients with an intact airway and escalating oxygen requirements, high flow nasal cannula oxygen therapy or noninvasive ventilation can be considered.[79]Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015 Jun 4;372(23):2185-96. https://www.nejm.org/doi/10.1056/NEJMoa1503326?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov http://www.ncbi.nlm.nih.gov/pubmed/25981908?tool=bestpractice.com [80]Qaseem A, Etxeandia-Ikobaltzeta I, Fitterman N, et al. Appropriate use of high-flow nasal oxygen in hospitalized patients for initial or postextubation management of acute respiratory failure: a clinical guideline from the American College of Physicians. Ann Intern Med. 2021 Jul;174(7):977-84. https://www.acpjournals.org/doi/full/10.7326/M20-7533?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/33900796?tool=bestpractice.com [81]Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017 Aug;50(2):1602426. https://publications.ersnet.org/content/erj?view=long&pmid=28860265 http://www.ncbi.nlm.nih.gov/pubmed/28860265?tool=bestpractice.com See Acute respiratory failure.
Assess volume status, paying particular attention to signs of volume depletion. Administer intravenous fluids as needed, and give nutritional support in prolonged illness.
pathogen-directed antibiotic therapy
A rarely identified cause of HAP is L pneumophila. Treatment may be with either a fluoroquinolone or a macrolide.
Systemic fluoroquinolone antibiotics, such as ciprofloxacin or levofloxacin or moxifloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[111]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10056716 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.
While fluoroquinolones are no longer licensed for the treatment of nosocomial pneumonia in Europe, they are still approved for this indication in the US and other countries, and guidelines still recommend their use.[1]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):e61-111. http://cid.oxfordjournals.org/content/63/5/e61.long http://www.ncbi.nlm.nih.gov/pubmed/27418577?tool=bestpractice.com Therefore, the use of fluoroquinolones is still recommended in this topic, although they should be used with caution.
Treatment course: 7-10 days.
Primary options
levofloxacin: 750 mg intravenously every 24 hours
OR
azithromycin: 500 mg intravenously every 24 hours
Secondary options
moxifloxacin: 400 mg intravenously every 24 hours
OR
ciprofloxacin: 400 mg intravenously every 8 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
levofloxacin: 750 mg intravenously every 24 hours
OR
azithromycin: 500 mg intravenously every 24 hours
Secondary options
moxifloxacin: 400 mg intravenously every 24 hours
OR
ciprofloxacin: 400 mg intravenously every 8 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
levofloxacin
OR
azithromycin
Secondary options
moxifloxacin
OR
ciprofloxacin
supportive care
Treatment recommended for ALL patients in selected patient group
Administer oxygen therapy as necessary. Monitor oxygen saturation and inspired oxygen concentration with the aim of maintaining SaO 2 above 92%.[77]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017 May 15;4(1):e000170. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531304 http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com [78]Barnett A, Beasley R, Buchan C, et al. Thoracic Society of Australia and New Zealand position statement on acute oxygen use in adults: 'swimming between the flags'. Respirology. 2022 Apr;27(4):262-76. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9303673 http://www.ncbi.nlm.nih.gov/pubmed/35178831?tool=bestpractice.com High concentrations of oxygen can safely be given in uncomplicated pneumonia. Oxygen therapy in patients with COPD complicated by ventilatory failure should be guided by repeated arterial blood gas measurements.[77]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017 May 15;4(1):e000170. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531304 http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com Patients with respiratory failure despite appropriate oxygen therapy require urgent airway management and possible intubation. For conscious patients with an intact airway and escalating oxygen requirements, high flow nasal cannula oxygen therapy or noninvasive ventilation can be considered.[79]Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015 Jun 4;372(23):2185-96. https://www.nejm.org/doi/10.1056/NEJMoa1503326?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov http://www.ncbi.nlm.nih.gov/pubmed/25981908?tool=bestpractice.com [80]Qaseem A, Etxeandia-Ikobaltzeta I, Fitterman N, et al. Appropriate use of high-flow nasal oxygen in hospitalized patients for initial or postextubation management of acute respiratory failure: a clinical guideline from the American College of Physicians. Ann Intern Med. 2021 Jul;174(7):977-84. https://www.acpjournals.org/doi/full/10.7326/M20-7533?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/33900796?tool=bestpractice.com [81]Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017 Aug;50(2):1602426. https://publications.ersnet.org/content/erj?view=long&pmid=28860265 http://www.ncbi.nlm.nih.gov/pubmed/28860265?tool=bestpractice.com See Acute respiratory failure.
Assess volume status, paying particular attention to signs of volume depletion. Administer intravenous fluids as needed, and give nutritional support in prolonged illness.
after culture results: due to gram-positive pathogen
pathogen-directed antibiotic therapy
Once cultures return, antibiotics should be de-escalated accordingly; that is, treatment should be narrowed based on the sensitivities of what particular pathogen grew, or antimicrobials should be discontinued based on what did not grow.
Linezolid or vancomycin can be given if the patient is allergic to penicillin or cephalosporin.
Treatment course: 7 days if patient is clinically stable; 14 days if associated with sepsis or complications.
Primary options
nafcillin: 2 g intravenously every 4 hours
OR
cefazolin: 1-2 g intravenously every 6 hours
Secondary options
linezolid: 600 mg intravenously every 12 hours
OR
vancomycin: 15 mg/kg intravenously every 12 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
nafcillin: 2 g intravenously every 4 hours
OR
cefazolin: 1-2 g intravenously every 6 hours
Secondary options
linezolid: 600 mg intravenously every 12 hours
OR
vancomycin: 15 mg/kg intravenously every 12 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
nafcillin
OR
cefazolin
Secondary options
linezolid
OR
vancomycin
supportive care
Treatment recommended for ALL patients in selected patient group
Administer oxygen therapy as necessary. Monitor oxygen saturation and inspired oxygen concentration with the aim of maintaining SaO₂ above 92%.[77]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017 May 15;4(1):e000170. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531304 http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com [78]Barnett A, Beasley R, Buchan C, et al. Thoracic Society of Australia and New Zealand position statement on acute oxygen use in adults: 'swimming between the flags'. Respirology. 2022 Apr;27(4):262-76. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9303673 http://www.ncbi.nlm.nih.gov/pubmed/35178831?tool=bestpractice.com High concentrations of oxygen can safely be given in uncomplicated pneumonia. Oxygen therapy in patients with COPD complicated by ventilatory failure should be guided by repeated arterial blood gas measurements.[77]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017 May 15;4(1):e000170. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531304 http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com Patients with respiratory failure despite appropriate oxygen therapy require urgent airway management and possible intubation. For conscious patients with an intact airway and escalating oxygen requirements, high flow nasal cannula oxygen therapy or noninvasive ventilation can be considered.[79]Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015 Jun 4;372(23):2185-96. https://www.nejm.org/doi/10.1056/NEJMoa1503326?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov http://www.ncbi.nlm.nih.gov/pubmed/25981908?tool=bestpractice.com [80]Qaseem A, Etxeandia-Ikobaltzeta I, Fitterman N, et al. Appropriate use of high-flow nasal oxygen in hospitalized patients for initial or postextubation management of acute respiratory failure: a clinical guideline from the American College of Physicians. Ann Intern Med. 2021 Jul;174(7):977-84. https://www.acpjournals.org/doi/full/10.7326/M20-7533?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/33900796?tool=bestpractice.com [81]Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017 Aug;50(2):1602426. https://publications.ersnet.org/content/erj?view=long&pmid=28860265 http://www.ncbi.nlm.nih.gov/pubmed/28860265?tool=bestpractice.com See Acute respiratory failure.
Assess volume status, paying particular attention to signs of volume depletion. Administer intravenous fluids as needed, and give nutritional support in prolonged illness.
pathogen-directed antibiotic therapy
Once cultures return, antibiotics should be de-escalated accordingly; that is, treatment should be narrowed based on the sensitivities of what particular pathogen grew, or antimicrobials should be discontinued based on what did not grow.
Linezolid is not inferior to vancomycin, and has not been shown to be superior.[90]Rubinstein E, Cammarata S, Oliphant T, et al. Linezolid (PNU-100766) versus vancomycin in the treatment of hospitalized patients with nosocomial pneumonia: a randomized, double-blind, multicenter study. Clin Infect Dis. 2001 Feb 1;32(3):402-12. http://cid.oxfordjournals.org/content/32/3/402.full http://www.ncbi.nlm.nih.gov/pubmed/11170948?tool=bestpractice.com [91]Wunderink RG, Cammarata SK, Oliphant TH. Continuation of a randomized, double-blind, multicenter study of linezolid versus vancomycin in the treatment of patients with nosocomial pneumonia. Clin Ther. 2003 Mar;25(3):980-92. http://www.ncbi.nlm.nih.gov/pubmed/12852712?tool=bestpractice.com [92]Kollef MH, Rello J, Cammarata SK, et al. Clinical cure and survival in Gram-positive ventilator-associated pneumonia: retrospective analysis of two double-blind studies comparing linezolid with vancomycin. Intensive Care Med. 2004 Mar;30(3):388-94. http://www.ncbi.nlm.nih.gov/pubmed/14714107?tool=bestpractice.com [93]Kalil AC, Murthy MH, Hermsen ED, et al. Linezolid versus vancomycin or teicoplanin for nosocomial pneumonia: a systematic review and meta-analysis. Crit Care Med. 2010 Sep;38(9):1802-8. http://www.ncbi.nlm.nih.gov/pubmed/20639754?tool=bestpractice.com [94]Walkey AJ, O'Donnell MR, Wiener RS. Linezolid vs glycopeptide antibiotics for the treatment of suspected methicillin-resistant Staphylococcus aureus nosocomial pneumonia: a meta-analysis of randomized controlled trials. Chest. 2011 May;139(5):1148-55. http://www.ncbi.nlm.nih.gov/pubmed/20864609?tool=bestpractice.com
Telavancin is approved for HAP/ventilator-associated pneumonia (VAP) when an alternative is not suitable. Data supporting its use show that it was noninferior to vancomycin when comparing cure rates. Cure was defined as improvement or lack of progression of baseline radiographic findings at the end of treatment and resolution of signs and symptoms of pneumonia at follow-up/test of cure.[119]Rubinstein E, Lalani T, Corey GR, et al. Telavancin versus vancomycin for hospital-acquired pneumonia due to gram-positive pathogens. Clin Infect Dis. 2011 Jan 1;52(1):31-40. http://cid.oxfordjournals.org/content/52/1/31.long http://www.ncbi.nlm.nih.gov/pubmed/21148517?tool=bestpractice.com
Treatment course: 7 days if patient is clinically stable; 14 days if associated with sepsis or complications. Telavancin can be used for 7-21 days.
Primary options
linezolid: 600 mg intravenously every 12 hours
OR
vancomycin: 15 mg/kg intravenously every 12 hours
Secondary options
telavancin: 10 mg/kg intravenously every 24 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
linezolid: 600 mg intravenously every 12 hours
OR
vancomycin: 15 mg/kg intravenously every 12 hours
Secondary options
telavancin: 10 mg/kg intravenously every 24 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
linezolid
OR
vancomycin
Secondary options
telavancin
supportive care
Treatment recommended for ALL patients in selected patient group
Administer oxygen therapy as necessary. Monitor oxygen saturation and inspired oxygen concentration with the aim of maintaining SaO 2 above 92%.[77]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017 May 15;4(1):e000170. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531304 http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com [78]Barnett A, Beasley R, Buchan C, et al. Thoracic Society of Australia and New Zealand position statement on acute oxygen use in adults: 'swimming between the flags'. Respirology. 2022 Apr;27(4):262-76. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9303673 http://www.ncbi.nlm.nih.gov/pubmed/35178831?tool=bestpractice.com High concentrations of oxygen can safely be given in uncomplicated pneumonia. Oxygen therapy in patients with COPD complicated by ventilatory failure should be guided by repeated arterial blood gas measurements.[77]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017 May 15;4(1):e000170. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531304 http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com Patients with respiratory failure despite appropriate oxygen therapy require urgent airway management and possible intubation. For conscious patients with an intact airway and escalating oxygen requirements, high flow nasal cannula oxygen therapy or noninvasive ventilation can be considered.[79]Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015 Jun 4;372(23):2185-96. https://www.nejm.org/doi/10.1056/NEJMoa1503326?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov http://www.ncbi.nlm.nih.gov/pubmed/25981908?tool=bestpractice.com [80]Qaseem A, Etxeandia-Ikobaltzeta I, Fitterman N, et al. Appropriate use of high-flow nasal oxygen in hospitalized patients for initial or postextubation management of acute respiratory failure: a clinical guideline from the American College of Physicians. Ann Intern Med. 2021 Jul;174(7):977-84. https://www.acpjournals.org/doi/full/10.7326/M20-7533?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/33900796?tool=bestpractice.com [81]Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017 Aug;50(2):1602426. https://publications.ersnet.org/content/erj?view=long&pmid=28860265 http://www.ncbi.nlm.nih.gov/pubmed/28860265?tool=bestpractice.com See Acute respiratory failure.
Assess volume status, paying particular attention to signs of volume depletion. Administer intravenous fluids as needed, and give nutritional support in prolonged illness.
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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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