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

Answer

Guidelines on management of adults with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) by the Infectious Diseases Society of America and the American Thoracic Society are as follows:^[3]

Recommend that each hospital generate antibiograms to guide healthcare professionals with respect to the optimal choice of antibiotics.
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.
Short-course antibiotic therapy is recommended for most patients with HAP or VAP regardless of microbial etiology, as well as antibiotic de-escalation.
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 who require empiric coverage for MRSA, vancomycin or linezolid is recommended.
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.

Recent studies have addressed the emergence of MDR pathogens and treatment approaches, as well as the role of biomarkers in diagnosis and length of therapy.^[22]

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Typical chest radiograph of a patient with nosocomial pneumonia.

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