New guidelines for managing hospital-acquired pneumonia

January 2005

BOSTON — New guidelines for managing hospital-acquired pneumonia (HAP) will stress the importance of initiating appropriate and adequate therapy and limiting the use of antibiotics to seven days in patients who are responding to therapy.

The guidelines — which are being introduced jointly by the IDSA and the American Thoracic Society (ATS) — are expected early this year, said Donald E. Craven, MD, of Lahey Clinic Medical Center and Tufts University School of Medicine here. He co-chaired the joint committee of experts with Michael S. Niederman, MD, of Winthrop University Hospital in Mineola, N.Y., and the State University of New York at Stonybrook.

“After 15 months of work by committee members, the guideline is finished,” Craven told an audience at the 42nd Annual Meeting of the Infectious Diseases Society of America, held here. “As you know, we used to have two societies writing similar guidelines,” so the two groups decided to pair up and come up with one uniform guideline. Craven said these guidelines differ significantly from the pneumonia guidelines that were last updated in 1996 by the ATS.

“Everybody here has treated hundreds of patients with pneumonia, and these patients are difficult to manage,” Craven said. “We often have to guess what antibiotics to use. What has changed now is the rapid emergence of multidrug-resistant (MDR) pathogens causing HAP, such as Pseudomonas aeruginosa, Acinetobacter spp and methicillin-resistant Staphylococcus aureus (MRSA), which has altered the strategy for selecting initial antibiotics that are both appropriate and adequately dosed.”

Craven said that those factors have prompted the guidelines’ authors to change the empiric regimens that are often used, as well as the dose and duration of recommended antibiotic therapy.

Another big change in these guidelines is the inclusion of health care–associated pneumonia, which, he said, is more similar to HAP and ventilator-associated pneumonia (VAP) than community-acquired pneumonia (CAP).

Four principles

Craven said the IDSA and the ATS will advocate four major principles in their document:

1. Avoiding inappropriate or inadequate antibiotic use
2. Recognizing variability in bacteriology. “Your empiric regimen has to be based on local microbiology in your hospital,” he said.
3. Avoiding overuse of antibiotics
4. Assessing risk factors for MDR pathogens

Craven said the guidelines will stress the importance of obtaining blood cultures and, when available, sputum specimens.

The guidelines also present a treatment algorithm to follow if the patient has an MDR pathogen. He said they encourage the initial use of broad-spectrum therapy. He said if the patient does not have a risk factor for MDR pathogens, the guidelines recommend using similar protocols to those for patients with CAP.

On the second or third day of therapy, the guidelines recommend checking the culture results and, if the patient is improving, de-escalating antibiotics. On the seventh day of treatment, the guidelines urge physicians to stop antibiotics if the patient has responded, Craven said.

He said another change in the guidelines is that in cases of MRSA, the dosage of vancomycin recommended has increased to 15 mg/kg every 12 hours compared with 10 mg/kg every 12 hours and maintaining higher trough levels. Linezolid (Zyvox, Pharmacia) is also used to treat HAP due to MRSA.

Finally, speaking on the recommendation to reduce the duration of antibiotics, Craven cited a study by committee members Chastre et al (JAMA. 2003;290:2588-2598) that examined 401 patients with VAP who were randomly assigned to receive either eight days or 15 days of therapy with an antibiotic regimen selected by the treating physician. In that study, researchers concluded that “among patients who had received appropriate initial empirical therapy, with the possible exception of those with VAP due to P. aeruginosa, comparable clinical effectiveness against VAP was obtained with the eight- and 15-day treatment regimens.”

Finally, Craven said, the guidelines stress the implementation of infection and other modifiable risk factors.

For more information:

• Craven DE. Pneumonia practice guidelines: community-acquired and nosocomial. Presented at the 42nd Annual Meeting of the Infectious Diseases Society of America. Sept. 30-Oct. 3, 2004. Boston.
• Craven DE, Palladino R, McQuillen DP. Healthcare-associated pneumonia in adults: management principles to improve outcomes. Infect Dis Clin N Am. 2004;18(4):939-962.
• Chastre J, Wolff M, Fagon JY, et al. Comparison of 8 vs. 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA. 2003;290(19):2588-2598.