AIIMS releases guideline on Hospital-Acquired Pneumonia

All India Institute of Medical Sciences, Delhi has released AIIMS Antibiotics Policy which has been prepared by the Department of Medicine with Multidisciplinary collaboration. The guidance for respiratory Infections includes hospital-acquired Pneumonia the salient features of which are hereunder.

Hospital-Acquired Pneumonia (HAP) occurs after more than 48 hours of admission and was apparently not incubating at the time of admission.

Ventilator-Associated Pneumonia (VAP) develops after more than 48 hours of mechanical ventilation.

When to suspect

The diagnosis is more often clinical with no gold standard diagnostic criteria. When a patient is hospitalized/on mechanical ventilation for > 48 hrs develops new or progressive infiltrates on a chest radiograph and has at least 2 of the following features: fever> 100.4o F; leucocytosis (>12000/µl) or leucopenia (<4000/ µl); altered mental status with no other recognizable cause in the elderly; new-onset purulent sputum or change in sputum character; worsening gas exchange (i.e. increased FiO2 requirement); new onset or worsening cough or dyspnea; rales or bronchial breathing.

How to confirm

HAP

Respiratory samples obtained by spontaneous expectoration, sputum induction or nasotracheal suctioning and are subjected to semiquantitative cultures. Culture growth is to be considered significant if ≥105 CFU/ml.

VAP

Respiratory specimens are obtained by Endotracheal aspiration or mini bronchoalveolar lavage (BAL) and subjected to semiquantitative cultures (Mini-BAL is preferred). The ideal sample collection procedure is however BAL.

Culture growth is considered to be significant if ≥105 CFU/ml for tracheal aspirate and ≥103 CFU/ml for BAL.

Treatment

Empiric antibiotic therapy should be initiated after sending the cultures.

Aetiology:

A) Empiric (VAP/HAP):

Preferred:

Cefoperazone –Sulbactam (3g IV BD)

Or

Imipenem-Cilastatin (0.5-1gm IV QID)

Or

Meropenem (1 g IV TDS)

Or

Piperacillin-Tazobactam (4.5 g IV QID)

plus

Amikacin (15–20 mg/kg IV OD)

Alternative:

Colistin (9MU IV stat followed by 4.5 MU IV BD)

Or

Polymyxin B (20000-25000U/kg loading f/b 25000 U/kg/day in two divided doses)

(To be used in combination with carbapenems/ BL-BLI inhibitors)

B) Culture proven VAP/HAP:

-Acinetobacter baumannii, Klebsiella pneumonia, Pseudomonas aeruginosa: Choose any one according to culture sensitivity from: Piperacillin-Tazobactam (4.5 g IV QID), Cefoperazone –Sulbactam (3g IV BD), Imipenem-Cilastatin (500 mg IV QID), Meropenem (1 g IV TDS), Colistin (9MU IV stat followed by 4.5 MU IV BD), Polymyxin B (20000-25000U/kg loading f/b 25000 U/kg/day in two divided doses)

-MRSA:

Preferred: Inj. Vancomycin (1g IV BD) or Inj. Linezolid (600 mg IV BD)

Alternative: Inj.Teicoplanin (400mg IV BD for 3 doses followed by 400mg IV OD)

Special Remarks:

1. 
   

   Levofloxacin (750 mg IV q24h) may be used as an alternative to amikacin as a second anti-pseudomonal agent.

   
   


2. 
   

   Nebulized Colistin at a dose of 2.25 to 4.5 MU twice daily or 3 MU thrice daily can be used along with IV Colistin.

   
   


3. 
   

   Colistin and Polymyxin B should be used only when there is resistance to all the other tested antibiotics.

   
   


4. 
   

   If a patient with suspected VAP has septic shock and rapidly deteriorating status, empiric MRSA coverage can be added.

   
   


5. 
   

   The choice between vancomycin and linezolid to be guided by patient-specific factors (blood cell counts, renal functions, concomitant nephrotoxic agents)

   
   


6. 
   

   De-escalation should be done once the culture reports are available.

   
   


7. 
   

   Recommended duration of therapy: 7 days if there is a good clinical response or longer if clinically indicated (immunodeficiency, empyema, lung abscess, cavitation, necrotising pneumonia, etc).

   
   


8. 
   

   HAP/VAP due to P. aeruginosa who remain in septic shock/ at high risk for the poor outcome when the results of antibiotic susceptibility testing are known, combination therapy using 2 antibiotics to which the isolates susceptible rather than monotherapy is preferred.

   
   


9. 
   

   Clinical picture and procalcitonin levels may be used to guide the discontinuation of antibiotics.

   
   


10. 
    

    Faropenem should not be used as a step-down therapy in VAP/HAP susceptible to Carbapenems.

    
    


11. 
    

    Tigecycline is not recommended routinely in the treatment of VAP.

    
    

C) Aspergillus Pneumonia:

Preferred: Voriconazole (6 mg/kg IV every 12 h for 1 d, followed by 4 mg/kg IV every 12 h; oral therapy can be used at 200–300 mg every 12 h)

Alternative: Liposomal AmB (3–5 mg/kg/day IV)

Special Remarks:

-Use Blot’s algorithm for the diagnosis of Aspergillus pneumonia in critically ill patients. [8]

-Primary combination therapy is not routinely recommended

-Therapeutic Drug Monitoring (TDM) should be done in patients receiving voriconazole (Range: 1-5 mg/L)