The Infectious Diseases Society of America and the American Thoracic Society recently updated their 2005 guidelines for the management of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP).
The 2016 recommendations differ from the prior guidelines in that they use the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology for evaluating evidence, remove the concept of health care-associated pneumonia from these HAP/VAP guidelines, and recommend that individual hospitals generate antibiograms to help clinicians choose the optimal antibiotics and decrease the unnecessary use of dual gram-negative and empiric antibiotic therapy for methicillin-resistant Staphylococcus aureus (MRSA). The new guidelines were published online on July 14 by Clinical Infectious Diseases.
The guidelines recommend short-course antibiotic therapy and antibiotic de-escalation for most patients with HAP or VAP, independent of microbial etiology. For patients with suspected HAP or VAP, they recommend using clinical criteria alone (rather than using, for example, serum procalcitonin plus clinical criteria) to decide whether or not to initiate antibiotic therapy. Dosing should be determined based on pharmacokinetic/pharmacodynamic data (e.g., antibiotic blood concentrations, extended and continuous infusions, and weight-based dosing for certain antibiotics) rather than the manufacturer's prescribing information.
In most patients with HAP or VAP, the guidelines recommend that MRSA be treated with either vancomycin or linezolid; that Pseudomonas aeruginosa be treated with monotherapy in patients without risk factors for antimicrobial resistance; and that Acinetobacter species be treated with either a carbapenem or ampicillin/sulbactam or, if the isolate is not susceptible, intravenous polymyxin (colistin or polymyxin B) with adjunctive inhaled colistin. The guidelines suggest that clinicians use de-escalated rather than fixed antibiotic therapy and that they use procalcitonin levels plus clinical criteria to guide the discontinuation of therapy.
The guidelines suggest a 7-day course of antimicrobial therapy for patients with HAP or VAP, although shorter or longer courses may be indicated. Most patients with suspected HAP should be treated non-empirically and based on the results of microbiologic studies performed on respiratory samples obtained noninvasively. For those who are treated empirically, the guidelines recommend an antibiotic with activity against S. aureus.
When empirically treating most patients with suspected VAP, clinicians should include coverage for S. aureus as well as P. aeruginosa and other gram-negative bacilli. In patients with VAP due to gram-negative bacilli that are only susceptible to aminoglycosides or polymyxins, the guidelines suggest both inhaled and systemic antibiotics over systemic antibiotics alone.