Hospital-acquired Pneumonia

• Hospital-acquired pneumonia is pneumonia occurring 48 hours or more after admission, and did not appear to be incubating on admission. See investigation and treatment guidelines in Hospital HealthPathways.
• Empiric treatment is based on pneumonia severity and risk for multidrug-resistant gram-negative bacilli (MDR-GNB).

  Cover for MDR-GNB organisms if:

  • MDR-GNB positive
  • Current or recent inpatient in a high-risk ward (e.g. ICU, BMTU, SPCU) for 5 days or more
  • Admission to overseas healthcare facility
  • Travel to developing country in previous six months
  • Household contact with MDR-GNB
  • Residence or admission to any facility with high prevalence of MDR-GNB
  • Broad-spectrum antimicrobial treatment.
• Severe hospital-acquired pneumonia is defined as the presence of one or more of the following:
  • rapid progression of infiltrates
  • severe sepsis/septic shock
  • need for intubation

Pathogens

• Common: H. influenzae, S. pneumoniae, Gram-negative organisms

Drug Treatment

• Duration: usually 5–7 days, depending on severity. Consult Infectious Diseases/Clinical Microbiology if slow to settle.

Empiric

Non-severe disease and low risk for MDR-GNBs

amoxicillin+clavulanic acid HMLSchedNZFPMLnoids Amoxicillin+Clavulanic Acid F: 0.9 / 0.5 Half life: 2 hours / 1 hour Elimination: renal fe: 0.9 / 0.5

IV 1 g/200 mg every eight hours then PO 500 mg/125 mg three times a day

• fe (amoxicillin) = 0.9, fe (clavulanic acid) = 0.5, consider adjusting dose if CrCl reduced.

Mild penicillin allergy

cefuroxime HMLSchedNZFPMLnoids Cefuroxime F: 0.4 Half life: 2 hours Elimination: renal fe: 0.9

IV 1.5 g every eight hours then PO 500 mg twice a day

• fe = 0.9, consider adjusting dose if CrCl is reduced.
• Cefuroxime is not funded for this indication on prescription – ask your ward pharmacist to supply on discharge.

Severe penicillin allergy

clindamycin HMLSchedNZFPMLnoids Clindamycin F: 0.9 Half life: 3 hours Elimination: CYP3A fe: 0.1

PO 450 mg three times a day (or IV 600 mg every eight hours)

• Metabolised by CYP3A. (fe < 0.1).

AND EITHER

gentamicin HMLSchedNZFPMLnoids Gentamicin F: n/a Half life: 3 hours Elimination: renal fe: 0.9 Additional points: TDM.

See dosing guidelines

• fe = 0.9, adjust dose if CrCl reduced.

OR

ciprofloxacin HMLSchedNZFPMLnoids Ciprofloxacin F: 0.7 Half life: 4 hours Elimination: renal fe: 0.5 Additional points: Inhibits CYP1A2 and 3A. Antacids, milk, and enteral feeds ↓ absorption.

PO 500 mg twice a day

• Inhibits CYP1A2 (strong) and 3A.
• Subject to OAT and OATP (transporter) inhibition.
• Avoid in pregnancy and breastfeeding.

Severe disease or high risk for MDR-GNBs

• Complex patient group – consult Infectious Diseases/Clinical Microbiology early.

piperacillin+tazobactam HMLNZFPMLnoids Piperacillin+Tazobactam F: n/a Half life: 1 hour Elimination: renal fe: 0.8/0.6

IV 4 g/500 mg every eight hours

• If still on piperacillin+tazobactam beyond 48 hours, consider measuring a trough concentration. Consult Infectious Diseases for interpretation.
• fe (piperacillin) = 0.8, fe (tazobactam) = 0.6, consider adjusting dose if CrCl reduced.

Mild penicillin allergy

meropenem HMLNZFPMLnoids Meropenem F: n/a Half life: 1 hour Elimination: renal; hydrolysis fe: 0.7

IV 1 g every eight hours

• Meropenem rapidly and significantly reduces sodium valproate concentrations. Concomitant administration may precipitate seizures in patients with a pre-existing seizure disorder. Discuss alternative antibiotic options with Infectious Diseases/Clinical Microbiology.
• If still on meropenem beyond 48 hours, consider measuring a trough concentration. Consult Infectious Diseases for interpretation.
• fe = 0.7, start with full dose initially then consider extending dose interval and/or decreasing dose for subsequent doses if CrCl is reduced (< 30 mL/min). Consult pharmacist.

Severe penicillin allergy

Consult Infectious Diseases/Clinical Microbiology/Respiratory Medicine.

Nosocomial legionella infection (notifiable)

This is unusual. If in doubt consult Infectious Diseases/Clinical Microbiology/Respiratory Medicine.

Topic Code: 99247

must be prescribed or recommended by a consultant.