Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia

Publication Date: July 14, 2016
Last Updated: December 16, 2022

Diagnosis

Microbiologic Methods

ATS and IDSA suggest noninvasive sampling with semiquantitative cultures to diagnose VAP, rather than invasive sampling with quantitative cultures and rather than noninvasive sampling with quantitative cultures. ( W , L)
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Noninvasive sampling with semiquantitative cultures is the preferred methodology to diagnose VAP. 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, ATS and IDSA suggest that antibiotics be withheld rather than continued. ( W , VL)
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ATS and IDSA 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. ( W , VL)
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Biomarkers

For patients with suspected HAP/VAP, ATS and IDSA recommend using clinical criteria alone, rather than using serum procalcitonin plus clinical criteria, to decide whether or not to initiate antibiotic therapy. ( S , M)
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For patients with suspected HAP/VAP, ATS and IDSA recommend using clinical criteria alone, rather than using bronchoalveolar fluid sTREM-1 plus clinical criteria, to decide whether or not to initiate antibiotic therapy. ( S , M)
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For patients with suspected HAP/VAP, ATS and IDSA recommend using clinical criteria alone rather than using C-Reactive Protein (CRP) plus clinical criteria, to decide whether or not to initiate antibiotic therapy. ( W , L)
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For patients with suspected HAP/VAP, ATS and IDSA suggest using clinical criteria alone, rather than using Modified Clinical Pulmonary Infection Score (CPIS) plus clinical criteria, to decide whether or not to initiate antibiotic therapy. ( W , L)
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Treatment

Initial

In patients with ventilator-associated tracheobronchitis (VAT) ATS and IDSA suggest NOT providing antibiotic therapy. ( W , L)
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ATS and IDSA recommend that all hospitals regularly generate and disseminate a local antibiogram, ideally one that is specific to their intensive care population(s) if possible.
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ATS and IDSA recommend that empiric treatment regimens be informed by the local distribution of pathogens associated with VAP and their antimicrobial susceptibilities. (, )
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In patients with suspected VAP, ATS and IDSA recommend including coverage for S. aureus, Pseudomonas aeruginosa, and other Gram-negative bacilli in all empiric regimens. ( S , L)
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ATS and IDSA suggest including an agent active against MRSA for the empiric treatment of suspected VAP only in patients with any of the following: a risk factor for antimicrobial resistance (Table 3), patients being treated in units where 10%–20% of S. aureus isolates are methicillin resistant, and patients in units where the prevalence of MRSA is not known. ( W , VL)
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ATS and IDSA suggest including an agent active against methicillin-sensitive S. aureus (MSSA) (and not MRSA) for the empiric treatment of suspected VAP in patients without risk factors for antimicrobial resistance, who are being treated in intensive care units (ICUs) where <10%–20% of S. aureus isolates are methicillin resistant. ( W , VL)
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If empiric coverage for MRSA is indicated, ATS and IDSA recommend either vancomycin or linezolid. ( S , M)
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When empiric treatment that includes coverage for MSSA (and not MRSA) is indicated, ATS and IDSA suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. ( W , VL)
  • Oxacillin, nafcillin, or 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.
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ATS and IDSA suggest prescribing two antipseudomonal antibiotics from different classes for the empiric treatment of suspected VAP only in patients with any of the following: a risk factor for antimicrobial resistance (Table 3), patients in units where >10% of Gram-negative isolates are resistant to an agent being considered for monotherapy, and patients in an ICU where local antimicrobial susceptibility rates are not available. ( W , L)
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ATS and IDSA suggest prescribing one antibiotic active against P. aeruginosa for the empiric treatment of suspected VAP in patients without risk factors for antimicrobial resistance who are being treated in ICUs where <10% of Gram-negative isolates are resistant to the agent being considered for monotherapy. ( W , L)
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In patients with suspected VAP, ATS and IDSA suggest avoiding aminoglycosides if alternative agents with adequate Gram-negative activity are available. ( W , L)
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In patients with suspected VAP, ATS and IDSA suggest avoiding colistin if alternative agents with adequate Gram-negative activity are available. ( W , VL)
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ATS and IDSA recommend that empiric antibiotic regimens be based upon the local distribution of pathogens associated with HAP and their antimicrobial susceptibilities. (, )
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ATS and IDSA recommend that all hospitals regularly generate and disseminate a local antibiogram, ideally one that is tailored to their HAP population, if possible. (, )
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For patients being treated empirically for HAP, ATS and IDSA recommend prescribing an antibiotic with activity against S. aureus. ( S , L)
(See below for recommendations regarding empiric coverage of MRSA vs MSSA.)
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For patients with HAP who are being treated empirically and have either a risk factor for MRSA infection (ie, prior intravenous antibiotic use within 90 days, hospitalization in a unit where 20% of S. aureus isolates are methicillin resistant, or the prevalence of MRSA is not known, or who are at high risk for mortality, ATS and IDSA suggest prescribing an antibiotic with activity against MRSA. ( W , VL)
  • (Risk factors for mortality include need for ventilatory support due to HAP and septic shock.)
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For patients with HAP who require empiric coverage for MRSA, ATS and IDSA recommend vancomycin or linezolid rather than an alternative antibiotic. ( S , L)
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For patients with HAP who are being treated empirically and have no risk factors for MRSA infection and are not at high risk of mortality, ATS and IDSA suggest prescribing an antibiotic with activity against MSSA. When empiric treatment that includes coverage for MSSA (and not MRSA) is indicated, ATS and IDSA suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. Oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven MSSA but are not necessary for empiric coverage of HAP if one of the above agents is used. ( W , VL)
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For patients with HAP who are being treated empirically, ATS and IDSA recommend prescribing antibiotics with activity against P. aeruginosa and other Gram-negative bacilli. ( S , VL)
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For patients with HAP who are being treated empirically and have factors increasing the likelihood for Pseudomonas or other Gram-negative infection (ie, prior intravenous antibiotic use within 90 days) or a high risk for mortality, ATS and IDSA suggest prescribing antibiotics from 2 different classes with activity against P. aeruginosa. ( W , VL)
  • (Risk factors for mortality include need for ventilatory support due to HAP and septic shock. All other patients with HAP who are being treated empirically may be prescribed a single antibiotic with activity against P. aeruginosa.)
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For patients with HAP who are being treated empirically, ATS and IDSA recommend NOT using an aminoglycoside as the sole antipseudomonal agent. ( S , VL)
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Optimization

For patients with HAP/VAP, ATS and IDSA suggest that antibiotic dosing be determined using Pharmacokinetic/Pharmacodynamic (PK/PD) data, rather than the manufacturer’s prescribing information. ( W , VL)
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Inhaled Antibiotic

For patients with VAP due to Gram-negative bacilli that are susceptible to only aminoglycosides or polymyxins (colistin or polymyxin B), ATS and IDSA suggest both inhaled and systemic antibiotics, rather than systemic antibiotics alone. ( W , VL)
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Pathogen-Specific Therapy

ATS and IDSA recommend that MRSAHAP/VAP be treated with either vancomycin or linezolid rather than other antibiotics or antibiotic combinations. ( S , M)
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For patients with HAP/VAP due to P. aeruginosa, ATS and IDSA recommend that the choice of an antibiotic for definitive (not empiric) therapy be based upon the results of antimicrobial susceptibility testing. ( S , L)
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For patients with HAP/VAP due to P. aeruginosa, ATS and IDSA recommend against aminoglycoside monotherapy. ( S , VL)
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For patients with HAP/VAP due to P. aeruginosa who are not in septic shock or at a high risk for death, and for whom the results of antibiotic susceptibility testing are known, ATS and IDSA recommend monotherapy using an antibiotic to which the isolate is susceptible rather than combination therapy. ( S , L)
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For patients with HAP/VAP due to P. aeruginosa who remain in septic shock or at a high risk for death when the results of antibiotic susceptibility testing are known, ATS and IDSA suggest combination therapy using 2 antibiotics to which the isolate is susceptible rather than monotherapy. ( W , VL)
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For patients with HAP/VAP due to P. aeruginosa, ATS and IDSA recommend against aminoglycoside monotherapy. ( S , VL)
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For patients with HAP/VAP due to extended-spectrum β-lactamase (ESBL)-producing Gram-negative bacilli, ATS and IDSA recommend that the choice of an antibiotic for definitive (not empiric) therapy be based upon the results of antimicrobial susceptibility testing and patient-specific factors. ( S , VL)
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In patients with HAP/VAP caused by Acinetobacter species, ATS and IDSA suggest treatment with either a carbapenem or ampicillin/sulbactam if the isolate is susceptible to these agents. ( W , L)
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In patients with HAP/VAP caused by Acinetobacter species that is sensitive only to polymyxins, ATS and IDSA recommend intravenous polymyxin (colistin or polymyxin B), ( S , L)
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and ATS and IDSA suggest adjunctive inhaled colistin. ( W , L)
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In patients with HAP/VAP caused by Acinetobacter species that is sensitive only to colistin, ATS and IDSA suggest NOT using adjunctive rifampicin. ( W , M)
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In patients with HAP/VAP caused by Acinetobacter species, ATS and IDSA recommend against the use of tigecycline. ( S , L)
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In patients with HAP/VAP caused by a carbapenem-resistant pathogen that is sensitive only to polymyxins, ATS and IDSA recommend intravenous polymyxins (colistin or polymyxin B), ( S , M)
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and ATS and IDSA suggest adjunctive inhaled colistin. ( W , L)
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For patients with VAP, ATS and IDSA recommend a 7-day course of antimicrobial therapy rather than a longer duration. ( S , M)
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For patients with HAP, ATS and IDSA recommend a 7-day course of antimicrobial therapy. ( S , VL)
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For patients with HAP/VAP, ATS and IDSA suggest that antibiotic therapy be de-escalated rather than fixed. ( W , VL)
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For patients with HAP/VAP, ATS and IDSA suggest using PCT levels plus clinical criteria to guide the discontinuation of antibiotic therapy, rather than clinical criteria alone. ( W , L)
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For patients with suspected HAP/VAP, ATS and IDSA suggest NOT using the CPIS to guide the discontinuation of antibiotic therapy. ( W , L)
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Recommendation Grading

Overview

Title

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia

Authoring Organizations

Publication Month/Year

July 14, 2016

Last Updated Month/Year

March 26, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Hospital, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Treatment, Management

Diseases/Conditions (MeSH)

D011014 - Pneumonia, D053717 - Pneumonia, Ventilator-Associated, D000077299 - Healthcare-Associated Pneumonia

Keywords

pneumonia, hospital-acquired pneumonia, ventilator-associated pneumonia, HAP, VAP, HCAP, healthcare association pneumonia

Source Citation

Andre C. Kalil, Mark L. Metersky, Michael Klompas, John Muscedere, Daniel A. Sweeney, Lucy B. Palmer, Lena M. Napolitano, Naomi P. O'Grady, John G. Bartlett, Jordi Carratalà, Ali A. El Solh, Santiago Ewig, Paul D. Fey, Thomas M. File, Jr, Marcos I. Restrepo, Jason A. Roberts, Grant W. Waterer, Peggy Cruse, Shandra L. Knight, Jan L. Brozek, 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, Volume 63, Issue 5, 1 September 2016, Pages e61–e111, https://doi.org/10.1093/cid/ciw353

Methodology

Number of Source Documents
364
Literature Search Start Date
July 1, 2012
Literature Search End Date
November 1, 2015