What are the IDSA/ATS treatment guidelines for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) in adults?

Answer

In 2016, the Infectious Disease Society of America and American Thoracic Society published guideline on management of adults with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP).^[4]^.The treatment discussion is congruent with these guidelines.

In order to tailor optimal choice of antibiotics and guide healthcare professionals, it is advised that each hospital generate facility specific antibiograms.
In an effort to minimize patient harm and exposure to unnecessary antibiotics and reduce the development of antibiotic resistance, the guidelines recommend that the antibiogram data be used to decrease the unnecessary use of dual gram-negative and empiric methicillin-resistant Staphylococcus aureus (MRSA) antibiotic treatment.
Suggest noninvasive sampling with semiquantitative cultures to diagnose VAP, rather than invasive sampling with quantitative cultures or noninvasive sampling with quantitative cultures.
However, the panel recognizes that invasive quantitative cultures will occasionally be performed by some clinicians. For patients with suspected VAP whose invasive quantitative culture results are below the diagnostic threshold for VAP, the guidelines suggest that antibiotics be withheld rather than continued.
Suggest that patients with suspected HAP (non-VAP) be treated according to the results of microbiologic studies performed on respiratory samples obtained noninvasively, rather than being treated empirically.
For patients with suspected HAP/VAP, the guidelines recommend using clinical criteria alone, rather than using serum procalcitonin (PCT) plus clinical criteria, bronchoalveolar lavage fluid (BALF) sTREM-1 plus clinical criteria, or C-reactive protein (CRP) plus clinical criteria to decide whether to initiate antibiotic therapy.
In patients with suspected VAP, include coverage for S aureus, Pseudomonas aeruginosa, and other gram-negative bacilli in all empiric regimens.
If empiric coverage for MRSA is indicated, either vancomycin or linezolid is recommended.
When empiric treatment that includes coverage for MSSA (and not MRSA) is indicated, the guidelines suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem.
Oxacillin, nafcillin, and cefazolin are preferred agents for treatment of proven MSSA, but are not necessary for the empiric treatment of VAP if one of the above agents is used.
For patients being treated empirically for HAP, prescribe an antibiotic with activity against S aureus.
For patients with HAP/VAP due to P aeruginosa, the guidelines recommend that the choice of an antibiotic for definitive (not empiric) therapy be based on the results of antimicrobial susceptibility testing.
For patients with VAP or HAP, a 7-day course of antimicrobial therapy is recommended, as well as antibiotic de-escalation. When the final culture and sensitivity results are available, the empiric broad-spectrum regimen should be converted to more narrow and specific coverage.

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Typical chest radiograph of a patient with nosocomial pneumonia.

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Author

Kartika Shetty, MD, FACP Program Director, Internal Medicine Residency Program, Sunrise GME; Facility Medical Director, TEAMHealth, Mountain View Hospital

Kartika Shetty, MD, FACP is a member of the following medical societies: American College of Physicians, Association of Program Directors in Internal Medicine, Medical Council of India

Disclosure: Nothing to disclose.

Coauthor(s)

Maycky Tang, DO Resident Physician, Department of Internal Medicine, Sunrise Health GME Consortium

Maycky Tang, DO is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Osteopathic Association

Disclosure: Nothing to disclose.

Leo Takashi Yamaguchi, MD Resident Physician, Department of Internal Medicine, Sunrise Health GME Consortium

Leo Takashi Yamaguchi, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Nazanin Sheikhan, MD Resident Physician, Department of Internal Medicine, Sunrise Health GME Consortium

Nazanin Sheikhan, MD is a member of the following medical societies: American Medical Association, American Medical Student Association/Foundation, American Federation for Medical Research, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Reza Vaghefi, MD Infectious Disease Physician, Infectious Disease Partners of Nevada (IDPN), Sunrise Health GME Consortium

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

John L Brusch, MD, FACP Corresponding Faculty Member, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

What are the IDSA/ATS treatment guidelines for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) in adults?

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