CAP HAP VAP

Most common bacterial causes of Community Acquired Pneumonia

Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydia pneumoniae

Ciprofloxacin usage in Community Acquired Pneumonia

Not used, as it is not a respiratory fluoroquinolone and does not cover Streptococcus pneumoniae

Duration of treatment for Community Acquired Pneumonia

5-7 days

Outpatient CAP Assessment - Healthy

No comorbidities

Outpatient CAP Assessment - High risk

With comorbidities

Healthy treatment options for CAP

Amoxicillin high dose (1 gram TID), Doxycycline, Macrolide (azithromycin, clarithromycin) if local pneumococcal resistance < 25%

High risk treatment options for CAP

Beta lactam + macrolide or doxycycline, Respiratory fluoroquinolone monotherapy

Preferred beta-lactams for non-severe inpatient CAP treatment

Ceftriaxone, ceftaroline, or ampicillin/sulbactam

Severe inpatient CAP treatment options

Beta-lactam + macrolide, Beta-lactam + respiratory fluoroquinolone

Risk factors for Pseudomonas and/or MRSA

Prior respiratory isolation or positive nasal swab; hospitalization and use of parenteral antibiotic in past 90 days

Hospital Acquired Pneumonia (HAP)

Onset > 48 hrs after hospital admission

Ventilator Associated Pneumonia (VAP)

Onset > 48 hrs after the start of mechanical ventilation

Treatment duration for HAP/VAP

7 days

Common pathogens in HAP/VAP

Nosocomial pathogens, MRSA, MDR gram negative, P. aeruginosa, Acinetobacter spp., Enterobacter spp., E. coli, Klebsiella spp.

HAP/VAP empiric treatment - all patients

Need antibiotic coverage for Pseudomonas and MSSA

Antibiotics for Pseudomonas coverage

Cefepime, Piperacillin/Tazobactam (Zosyn), Levofloxacin

Add vancomycin or linezolid if risk for MRSA

Risk factors: IV abx in past 90 days, MRSA prevalence in hospital unit > 20%, prior MRSA infection or positive MRSA nasal swab

Combination for Pseudomonas coverage with MRSA risk

Cefepime + vancomycin, Aztreonam + vancomycin, Meropenem + linezolid

Use two Pseudomonas antibiotics if risk for MDR gram negative pathogens

Risk factors: IV abx use in past 90 days, prevalence of gram negative resistance in hospital unit > 10%, hospitalized ≥ 5 days prior to onset of VAP

Example combination for Pseudomonas coverage

Piperacillin/Tazobactam (Zosyn) + ciprofloxacin + vancomycin, Cefepime + gentamicin + linezolid

Antibiotics for Pseudomonas

Do not use two beta lactams together

Beta-lactams for Pseudomonas

Piperacillin/Tazobactam (Zosyn), cefepime, ceftazidime, imipenem/cilastatin, meropenem

Other antibiotics for Pseudomonas

Levofloxacin, ciprofloxacin, Aztreonam, Aminoglycosides (Tobramycin) with another antipseudomonal drug