Hospital-Acquired Pneumonia Management (IDSA/ATS 2016)

Algorithm Steps

1. ▶

   Start

   Suspected HAP

   Pneumonia ≥48h after hospital admission

   1. ●

      Action

      Confirm Diagnosis

      Clinical + radiographic criteria

      • New/progressive infiltrate on CXR
      • Plus ≥2: fever, leukocytosis/leukopenia
      • Purulent secretions, declining oxygenation
      • Obtain respiratory cultures (sputum or BAL)
      • Blood cultures x2
      1. ◆

         Decision

         Assess MDR Risk Factors

         Determine coverage needed

         • IV antibiotics in prior 90 days
         • High local resistance (>10-20%)
         • Structural lung disease
         • Prior MDR isolation
         • Hospitalization ≥5 days
         1. ●

            Action

            Low MDR Risk

            Standard coverage

            • Piperacillin-tazobactam, OR
            • Cefepime, OR
            • Levofloxacin, OR
            • Imipenem or meropenem
            1. ◆

               Decision

               MRSA Risk Factors?

               Prior MRSA, high local MRSA, severe illness

               • Prior MRSA colonization/infection
               • IV antibiotics in prior 90 days
               • High MRSA prevalence unit (>10-20%)
               • Consider if unknown
               1. ●

                  Action

                  Add MRSA Coverage

                  Vancomycin or linezolid

                  • Vancomycin: trough 15-20 mg/L
                  • Linezolid: 600mg IV q12h
                  • Linezolid may be preferred in renal impairment
                  1. ◆

                     Decision

                     Reassess at 48-72h

                     Review cultures, clinical response

                     • Review culture results
                     • De-escalate if possible
                     • Assess clinical improvement
                     • Consider broadening if deteriorating
                     1. ●

                        Action

                        De-escalate Therapy

                        Narrow based on cultures

                        • Target identified pathogen(s)
                        • Switch to narrowest effective agent
                        • Consider PO switch if improving
                        • Stop MRSA coverage if cultures negative
                        1. ✓

                           Outcome

                           Treatment Duration

                           7 days recommended for uncomplicated HAP

                           • 7 days: standard duration
                           • Consider shorter if rapid improvement
                           • Longer if: Pseudomonas, abscess, empyema
                           • Serial procalcitonin may guide
                     2. ⚠

                        Warning

                        No Clinical Improvement

                        Consider alternative diagnoses

                        • Repeat imaging
                        • Consider bronchoscopy/BAL
                        • Evaluate for empyema, abscess
                        • Consider non-infectious causes
                        • ID consultation
               2. ●

                  Action

                  No MRSA Coverage

                  Gram-negative focused

         2. ●

            Action

            High MDR Risk

            Double gram-negative + MRSA coverage

            • Anti-pseudomonal beta-lactam
            • PLUS second anti-pseudomonal agent
            • (aminoglycoside OR fluoroquinolone)
            • PLUS MRSA coverage if risk factors