Pneumonia, healthcare-associated

Healthcare-associated pneumonia (HCAP), or pneumonia acquired outside the hospital in patients with healthcare-associated risk factors, is no longer distinguished in the guidelines. We recommended that most patients admitted for pneumonia who have had recent contact with the healthcare system (i.e., within 90 days, dialysis) be treated for CAP.
Diagnosis Common Pathogens Drug(s) of First Choice Alternative Drug(s) Comments Expected Duration

Pneumonia in patient admitted from skilled nursing or other long term care facility after at least one week stay, admitted to the floor

S. pneumoniae

S. aureus

H. influenzae

Enteric Gram negative bacilli

P. aeruginosa

Vancomycin

PLUS one of

Ertapenem

OR

Cefepime

OR

Piperacillin/tazobactam

For severe beta-lactam allergy

Vancomycin

PLUS

Levofloxacin

Obtain sputum for Gram stain and culture

Stop vancomycin at 48 hours if admission MRSA PCR is negative and/or no MRSA isolated from clinical cultures
5 days
Pneumonia with significant prior healthcare exposure, admitted to ICU

S. pneumoniae

S. aureus

H. influenzae

Enteric Gram negative bacilli

P. aeruginosa

Legionella

Vancomycin

PLUS one of

Ertapenem

OR

Cefepime

OR

Piperacillin/tazobactam

PLUS

Azithromycin

For severe beta-lactam allergy:

Vancomycin

PLUS

Aztreonam

PLUS

Azithromycin

Obtain sputum  or tracheal aspirate for Gram stain and culture

Patients coming from long-term acute care facilities are at high risk for resistant organisms; consider additional gram-negative coverage
5 days

ZSFG and SFVA Hospital-acquired pneumonia

EARLY ONSET including ventilator-associated OR–

< 5 days of hospitalization, no risk factors for drug-resistant organisms*

Staph. aureus

S.pneumoniae

H.influenzae

 

Antibiotic sensitive enteric gram negative bacilli:

E. coli

Enterobacter aerogenes

Klebsiella pneumoniae

Proteus mirabilis

Serratia marcesans

Vancomycin

PLUS one of EITHER:

Levofloxacin 750mg IV daily

OR

Ertapenem

 

*Risk factors include recent antibiotic exposure (within 30 days)

 

Consider influenza testing and treatment with oseltamivir when influenza is known to be circulating

7 days

ZSFG and SFVA Hospital-acquired pneumonia

LATE ONSET

including ventilator-associated OR (≥ 5 days of hospitalization or risk factors for resistant organisms)

E. coli

Enterobacter aerogenes

P. aeruginosa

Klebsiella pneumoniae

S. aureus

Vancomycin

PLUS one of EITHER:

Piperacillin/tazobactam

OR

Cefepime

 

Alternatively:

Vancomycin

PLUS

Meropenem**

For severe PCN allergy:

Vancomycin

PLUS

Aztreonam

WITH OR WITHOUT***:

Tobramycin

*Risk factors include recent antibiotic exposure (within 30 days)

 

**Consider use in patients with current or recent use (< 7 days) of piperacillin/tazobactam or cefepime and in patients with recent infection with multidrug resistant gram-negative bacteria

 

 ***Weigh risks and benefits of adding aminoglycoside for critical illness, immunocompromise, or history of infection or colonization with drug-resistant Gram-negative rods

7 days
UCSFMC Hospital-acquired and Ventilator-associated pneumonia UCSF Guidelines for Hospital-acquired/Ventilator-associed Pneumonia 7 days

Clinical Infectious Diseases, Volume 63, Issue 5, 1 September 2016, Pages e61–e111, https://doi.org/10.1093/cid/ciw353