Back to Basics: Hospital and Ventilator-Acquired Pneumonia

Back to Basics - Hospital-Acquired & Ventilator-Acquired Pneumonia

By: Kristen Adorno

Per 2016 IDSA-ATS Guidelines, it is recommended to no longer use the category of healthcare-associated pneumonia 

Hospital-Acquired Pneumonia (HAP)

  • Defined by pneumonia beginning ≥ 48 hours after hospital admission
  • Common pathogens: Staphylococcus aureus (MRSA, MSSA), Pseudomonas aeruginosa, Streptococcus pneumoniae, Haemophilus influenzae, and other gram-negative bacilli (Escherichia coli, Klebsiella pneumoniae, Enterobacter spp, Pseudomonas aeruginosa, Acinetobacter spp)
  • Treatment:
    • At minimum, MSSA + pseudomonas coverage: Piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem
    • If septic shock or requiring ventilatory support: Cover MRSA with double pseudomonas coverage (see VAP treatment below)
    • If hospital has >20% MRSA in staph aureus isolates, cover MRSA: Amikacin, gentamicin, tobramycin, levofloxacin or ciprofloxacin
    • If patient has structural lung disease or if anti-pseudomonal coverage has >10% resistance to pseudomonas, or if gram stain has an abundance of GNB: add second anti-pseudomonal agent with different mechanism of action - Amikacin, gentamicin, tobramycin, levofloxacin or ciprofloxacin 

Ventilator-Acquired Pneumonia (VAP)

  • Defined by pneumonia beginning ≥ 48 hours after starting mechanical ventilation
  • Common pathogens: Staphylococcus aureus (MRSA, MSSA), Pseudomonas aeruginosa, Klebsiella pneumoniae, Enterobacter species, Acinetobacter baumannii, and Escherichia coli
  • Treatment:
    • MRSA coverage: Amikacin, gentamicin, tobramycin, levofloxacin or ciprofloxacin
    • Double pseudomonas coverage: Piperacillin-tazobactam, cefepime, ceftazidime, imipenem, meropenem, or aztreonam PLUS amikacin, gentamicin, tobramycin, levofloxacin or ciprofloxacin

References

American College of Emergency Physicians., Tintinalli, J. E., et al. (2016). Tintinalli's emergency medicine manual (8th ed.). New York: McGraw-Hill Medical.

Kalil AC 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. Clinical Infectious Diseases. 2016; 63(5):61–111.

Kaysin, A. Community-acquired pneumonia in adults: Diagnosis and management. American Family Physician. 2016; 94(9):698-706.

Lionel A. Mandell. Community-acquired pneumonia: An overview. Postgraduate Medicine. 2015; 127:6, 607-615.

Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia: An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019; 200(7):45-67.

Sievert DM et al. Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010. Infect Control Hosp Epidemiol. 2013; 34(1):1-14.