Hospital-acquired pneumonia (HAP)

J12.0-3/J12.8-9/J13/J14/J15.0-9/J16.0/J16.8/J18.0-2/J18.8-9 + (Y95)

DESCRIPTION

HAP is defined as a new lung infiltrate (not present on admission) plus clinical evidence that the infiltrate is an infection (e.g. new onset of fever, purulent sputum, leukocytosis) occurring >48 hours after admission to hospital. HAP has a high morbidity and mortality and early appropriate antibiotic therapy is essential.

Infection may be due to multi-drug resistant organisms, particularly in patients with prior intravenous antibiotic use within 90 days.

LoEIII [13]

Ventilator-associated pneumonia (VAP) ocurs >48 hours after intubation. VAP is more often due to multi-drug resistant organisms than HAP.

Microbiologic specimens: blood culture and sputum/tracheal aspirate bacterial culture. Therapy should be adjusted according to culture result. A good quality Gram stain may be useful in guiding the choice of initial therapy.

MEDICINE TREATMENT

Empiric antibiotic therapy

Duration: 10 days.

HAP with no prior intravenous antibiotic use within 90 days:

  • Ceftriaxone, IV, 2 g daily.

and

  • Amikacin, IV, 15 mg/kg daily.

Severe Penicillin allergy: (Z88.0)

  • Moxifloxacin, oral/IV, 400 mg daily.

and

  • Amikacin, IV, 15 mg/kg daily.
  • (See AMIKACIN, IV for individual dosing and monitoring for response and toxicity).

HAP with prior intravenous antibiotic use within 90 days and VAP.

Antibiotic choice will depend on local susceptibility patterns. One or more of the following antibiotics/classes must be available, dependant on local susceptibility patterns:

  • Piperacillin/tazobactam, IV, 4.5 g 8 hourly.

and

  • Amikacin, IV, 15 mg/kg daily.
  • (See AMIKACIN, IV for individual dosing and monitoring for response and toxicity).

LoEIII [14]

OR

  • Cefepime, IV, 2 g 12 hourly.
  • (See CEFEPIME, IV for individual dosing and monitoring for response and toxicity).

LoEIII [15]

OR

Instead of piperacillin/tazobactam + amikacin OR cefepime:

Carbapenem with activity against Pseudomonas:

  • Imipenem/cilastan, IV, 1000/1000 mg 8 hourly (except CNS infections or known epileptics).

LoEIII [16]

OR

Instead of piperacillin/tazobactam + amikacin OR cefepime OR imipenem:

  • Meropenem, IV, 2 g 8 hourly (CNS infections or known epileptics).

Note: De-escalate as soon as the culture is available.