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ARTICLE

Changes in Therapy Guideline for Nosocomial Pneumonia

MAY 08, 2017 | KHALID ELJAALY, PHARMD, BCPS, CAPP
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 × (1.5 × 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
Current Guideline Previous Guideline
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 No statement
Dosing of polymyxins was added Not mentioned
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.
 
References:
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  7. 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.
  8. 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.
  9. 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.


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