Treatment of Hospital-Acquired and Ventilator-Associated ...
嚜激ffective Date: 6/25/2019. Contact CCKM@ for previous versions.
Treatment of Hospital-Acquired and
Ventilator-Associated Pneumonia - Adult Inpatient Clinical Practice Guideline
Note: Active Table of Contents 每 Click each header below to jump to the section of interest
Table of Contents
INTRODUCTION .................................................................................................................................3
SCOPE................................................................................................................................................3
DEFINITIONS ......................................................................................................................................3
RECOMMENDATIONS .........................................................................................................................4
METHODOLOGY .................................................................................................................................9
COLLATERAL TOOLS & RESOURCES ................................................................................................... 12
APPENDIX A. MANAGEMENT OF SUSPECTED HAP OR VAP ................................................................ 13
REFERENCES .................................................................................................................................... 14
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Copyright ? 2019 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee
Vermeulen, CCKM@
Last Revised: 06/2019
CCKM@
Effective Date: 6/25/2019. Contact CCKM@ for previous versions.
Content Expert:
Lucas Schulz, PharmD, BCIDP 每 Pharmacy
Phone Number: (608) 890-8617
Email Address: LSchulz2@
Contact for Changes:
Name: Philip Trapskin, PharmD, BCPS 每 Pharmacy Services & Drug Policy Program
Phone Number: (608)-263-1328
Email Address: PTrapskin@
Guideline Authors:
Chloe Schmidt, PharmD 每 Pharmacy
Katherine Cinnamon, PharmD, BCPS, BCIDP 每 Pharmacy
Lucas Schulz, PharmD, BCIDP 每 Pharmacy
Workgroup Members:
Derrick Chen, MD 每 Laboratory
Scott Ensminger, MD 每 General Medicine & Hospitalist
Jeffrey Fish, PharmD, BCCCP, BCPS 每 Pharmacy
Barry Fox, MD 每 Infectious Diseases
Alexander Lepak, MD 每 Infectious Diseases
Joseph McBride, MD 每 Infectious Diseases
Joshua Medow, MD 每 Neurosurgery
James Runo, MD 每 Advanced Pulmonology & Critical Care
Joshua Shapiro, MD 每 General Medicine & Hospitalist
Committee Approvals:
Antimicrobial Use Subcommittee: June 2019
Pharmacy & Therapeutics Committee: June 2019
2
Copyright ? 2019 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee
Vermeulen, CCKM@
Last Revised: 06/2019
CCKM@
Effective Date: 6/25/2019. Contact CCKM@ for previous versions.
Introduction
Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) account for
approximately 22% of all hospital-acquired infections.1 VAP mortality is estimated at 13% and HAP
patients (particularly those requiring ICU care) have similarly poor prognoses.2-5 VAP patients have
prolonged hospital stays and subsequently increased healthcare costs. HAP is associated with serious
complications including respiratory failure, pleural effusions, septic shock, renal failure, and empyema in
over 50% of cases.3,6,7 Accurate diagnosis and early empiric therapy have the potential to improve patient
outcomes in HAP and VAP. Appropriate antibiotic de-escalation and duration of therapy minimize the
emergence of antibiotic adverse drug events and antibiotic resistance.
Scope
Intended Users: Physicians, Advanced Practice Providers, Nurses, Pharmacists and Respiratory
Therapists
Objective: To provide evidence-based recommendations for the treatment of hospital-acquired and
ventilator-associated pneumonia
Target Population: Adult inpatients (excluding patients with cystic fibrosis) with suspected or confirmed
hospital-acquired and ventilator-associated pneumonia
Clinical Questions Considered:
? What diagnostic methods may be useful in guiding the treatment of HAP and VAP?
? Which antibiotics should be used for the empiric treatment of HAP and VAP?
? What is the optimal duration of antibiotic therapy for patients treated for HAP and VAP?
? How can exposure to unnecessary antibiotic therapy and patient harm be reduced in patients with
HAP and VAP?
? What are the differences in treatment approach between aspiration pneumonitis and aspiration
pneumonia?
Definitions
1. Hospital-acquired pneumonia (HAP): Pneumonia occurring 5 days or more after hospital admission
not associated with mechanical ventilation and not incubating at the time of hospital admission.8
2. Ventilator-associated pneumonia (VAP): Pneumonia occurring over 48 hours after endotracheal
intubation.8
3. Ventilator-associated tracheobronchitis (VAT): Fever with no other recognizable cause, new or
increased sputum production and positive endotracheal aspirate (>10 6 CFU/mL) yielding a new
bacteria and no radiographic evidence of pneumonia.8
4. Community-acquired bacterial pneumonia (CABP or CAP): Pneumonia occurring prior to
admission or up to 5 days after admission, that is typically caused by standard respiratory bacteria.9-12
5. Severe community-acquired pneumonia: Pneumonia with a CURB-65 score ≡3, PSI/PORT score
>130 or pneumonia requiring treatment in an intensive care unit (ICU). 10,13,14
6. Aspiration pneumonia: Pneumonia occurring after the inhalation of colonized oropharyngeal
contents with increased risk for an anaerobic burden of microrganisms. 15
7. Aspiration pneumonitis: Chemical lung injury precipitated by inhalation of sterile gastric contents.
Although often confused with CABP, only one quarter of patients with macroaspiration events leading
to pneumonitis develop a superimposed bacterial pneumonia (typically 2 to 7 days after the event). 16
8. Double coverage: Refers to two antibiotics, typically from separate classes, which cover
Pseudomonas aeruginosa or other Gram-negative bacteria with the intent to increase the likelihood of
choosing an antibiotic which has susceptibility against the bacteria (e.g. cefepime and tobramycin).
9. Combination therapy: Refers to two antibiotics that cover different bacteria (e.g. vancomycin
covering methicillin-resistant Staphylococcus aureus and cefepime covering Pseudomonas
aeruginosa).
3
Copyright ? 2019 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee
Vermeulen, CCKM@
Last Revised: 06/2019
CCKM@
Effective Date: 6/25/2019. Contact CCKM@ for previous versions.
Recommendations
1. Microbiologic methods to guide the treatment of HAP and VAP
1.1. In patients with HAP, an expectorated sputum sample is recommended for Gram stain and
culture prior to administration or within 24 hours of antimicrobial initiation, to allow for deescalation of therapy and reduce the risk of the emergence of multi-drug resistant (MDR)
organisms.8,17-19 (UW Health GRADE very low quality evidence, conditional recommendation)
1.1.1. If unable to obtain an expectorated sample within 4 hours, it is reasonable to consider
collection of an induced sputum. (UW Health GRADE very low quality evidence,
conditional recommendation)
1.1.2. We suggest that patients with suspected HAP (non-VAP) be treated according to the
results of microbiologic studies performed on respiratory samples obtained noninvasively,
rather than being treated empirically.8 (IDSA/ATS GRADE weak recommendation, very
low quality evidence)
1.1.3. For patients who are unable to provide a noninvasive respiratory culture, it is reasonable
to consider more invasive sampling with BAL or mini-BAL to guide treatment of HAP.20
(UW Health GRADE low quality evidence, conditional recommendation)
1.2. In patients with VAP, it is reasonable to consider invasive sampling with BAL or mini-BAL to
guide antimicrobial therapy rather than endotracheal aspirates or brushings. 20 (UW Health
GRADE very low quality evidence, conditional recommendation)
1.2.1. Noninvasive sampling with semiquantitative cultures is the preferred methodology to
diagnose VAP; however, the panel recognizes that invasive quantitative cultures will
occasionally be performed by some clinicians. For patients with suspected VAP whose
invasive quantitative culture results are below the diagnostic threshold for VAP [BAL with
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