Whereas the previous guideline did not discuss tigecycline and doripenem, the new guideline states that these medications were associated with worse outcomes in patients with VAP. Aminoglycosides were only recommended as adjunctive agents, not as the sole empiric antipseudomonal antibiotic, for patients with HAP. Interestingly, the new guideline states that it is acceptable to use aztreonam as an adjunctive antibiotic with another beta-lactam–based antibiotic in the absence of other options because of having different targets in the bacterial cell wall.
Sixth, the new guideline makes some changes regarding antibiotic dosing. Although the previous guideline did not provide a recommended dose for any polymyxin, the new guideline recommends dosing colistin as a 5-mg/kg IV as a loading dose, followed by a maintenance dose of a 2.5-mg ×
creatinine clearance + 30) IV every 12 hours, whereas it recommends dosing polymyxin B as 2.5 to 3 mg/kg/day divided in 2 daily IV doses. The cefepime and aminoglycosides doses were modified as following: the cefepime IV dose was changed from 1 to 2 g every 8 to 12 hours to 2 g every 8 hours; gentamicin and tobramycin IV doses were changed from 7 mg/kg/day to 5 to 7 mg/kg/day; and the amikacin IV dose was changed from 20 mg/kg/day to 15 to 20 mg/kg/day. Moreover, the new guideline recommends considering a loading dose of vancomycin for severe infections and extended IV infusion for piperacillin/tazobactam, cefepime, ceftazidime, imipenem, and meropenem, as well as basing antibiotic dosing on the pharmacokinetic/pharmacodynamic properties data rather than the manufacturer’s prescribing information.
Finally, the new guideline discusses the use of biomarkers to treat VAP and HAP. Procalcitonin, soluble triggering receptor expressed on myeloid cells, and C-reactive proteins were not recommended to be used to decide whether to initiate antibiotic therapy; however, procalcitonin was suggested in addition to clinical criteria to guide the antibiotic therapy discontinuation as it was associated with decreased antibiotic exposure without increasing adverse outcomes.7,8
In conclusion, the new guideline for HAP and VAP no longer includes HCAP. One antipseudomonal agent is currently recommended for most HAP and VAP cases unless patients have high risk for MDR pathogens, while MSSA coverage is needed in patients with VAP. Various changes and additions were made to antibiotic choice, dose, route of administration, and duration of therapy. A summary of the changes is included in the Table
Table: Updates to IDSA/ATS Guideline for Nosocomial Pneumonia Snapshot
|HCAP will be included with CAP
||HCAP was included in the spectrum of HAP/VAP
|Suggest 2 empiric antipseudomonal agents only for selected patients
||Recommend 2 empiric antipseudomonal agents for all
patients at high risk for MDR bacteria
|Recommend empiric coverage of MSSA in VAP
||No empiric coverage of MSSA in VAP
|All patients need empiric antipseudomonal agent
||Agents without antipseudomonal activity are acceptable
in some cases
|Suggest procalcitonin plus clinical criteria to guide antibiotic discontinuation
|Dosing of polymyxins was added
|Cefepime IV: 2 g every 8 hours
||Cefepime IV: 1-2 g every 8-12 hours
|Gentamicin and tobramycin IV: 5-7 mg/kg/day
||Gentamicin and tobramycin IV: 7 mg/kg/day
|Amikacin IV: 15-20 mg/kg/day
||Amikacin IV: 20 mg/kg/day
HCAP indicates healthcare-associated pneumonia; CAP, community-acquired pneumonia; VAP, ventilator-acquired pneumonia;
HAP, hospital-acquired pneumonia; MDR, multidrug resistant; MSSA, methicillin-susceptible Staphylococcus aureus
Dr. Eljaaly, PharmD, BCPS, is a postdoctoral pharmacy fellow in infectious diseases/antibiotic stewardship in the College of Pharmacy at the University of Arizona in Tucson, Arizona. He is a member of the stewardship committee in the SIDP and a member of Social Media Committee in both the SIDP and Infectious Diseases Practice and Research Network of the American College of Clinical Pharmacy.
- Kalil AC, Metersky ML, Klompas M, et al. 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. Clin Infect Dis. 2016;63(5):e61-e111. doi: 10.1093/cid/ciw353.
- American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416.
- Chalmers JD, Rother C, Salih W, Ewig S. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis. Clin Infect Dis. 2014;58(3):330-339. doi: 10.1093/cid/cit734.
- Gross AE, Van Schooneveld TC, Olsen KM, et al. Epidemiology and predictors of multidrug-resistant community-acquired and health care-associated pneumonia. Antimicrob Agents Chemother. 2014;58(9):5262-5268. doi: 10.1128/AAC.02582-14.
- Yap V, Datta D, Metersky ML. Is the present definition of health care-associated pneumonia the best way to define risk of infection with antibiotic-resistant pathogens? Infect Dis Clin North Am. 2013;27(1):1-18. doi: 10.1016/j.idc.2012.11.002.
- Jones BE, Jones MM, Huttner B, et al. Trends in antibiotic use and nosocomial pathogens in hospitalized veterans with pneumonia at 128 medical centers, 2006-2010. Clin Infect Dis. 2015;61(9):1403-1410. doi: 10.1093/cid/civ629.
- Valles J, Martin-Loeches I, Torres A, et al. Epidemiology, antibiotic therapy and clinical outcomes of healthcare-associated pneumonia in critically ill patients: a Spanish cohort study. Intensive Care Med. 2014;40(4):572-581. doi: 10.1007/s00134-014-3239-2.
- Schuetz P, Briel M, Christ-Crain M, et al. Procalcitonin to guide initiation and duration of antibiotic treatment in acute respiratory infections: an individual patient data meta-analysis. Clin Infect Dis. 2012;55(5):651-662. doi: 10.1093/cid/cis464.
- Schuetz P, Müller B, Christ-Crain M, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev. 2012;(9):CD007498. doi: 10.1002/14651858.CD007498.pub2.