Hospital-acquired pneumonia medical therapy
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Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; Associate Editor(s)-In-Chief: Priyamvada Singh, M.D. [2]
Overview
Methicillin-resistant staphylococcus aureus is a common isolate in the patients with Hospital-acquired pneumonia. The treatment options commonly used are vancomycin, linezolid, and clindamycin. Linezolid may be preferred in patients with renal insufficiency as the nephrotoxicity with Linezolid is less compared to vancomycin. Additionally, in patients with vancomycin MIC ≥ 2mcg/mL linezolid is preferred. Linezolid resistance and failure are rare.
Stepwise management strategies in suspected health care associated pneumonia, hospital acquired pneumonia, and ventilator-associated pneumonia (DONOT EDIT) [1]
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Antimicrobial therapy
Methicillin-resistant staphylococcus aureus
High risk patients
- Critically ill patients
- History of recent antibiotic therapy
- Patient admitted in a hospital with increased incidence of MRSA.
Antibiotic choice for MRSA
- Vancomycin (15-20 mg/kg Q8hrly or Q12 hrly in patients with normal renal funcion and target vancomycin of 15 - 20 mg/L)
- Linezolid - 600 mg twice daily IV or orally
- Teicoplanin
- Clindamycin if documented susceptibility present
- In case no MRSA is isolated on culture these antibiotics should be discontinued.
Advantages of linezolid over vancomycin
Methicillin-resistant staphylococcus aureus is a common isolate in the patients with Hospital-acquired pneumonia. The treatment options commonly used are vancomycin, linezolid, and clindamycin. Linezolid may be preferred in patients with renal insufficiency as the nephrotoxicity with Linezolid is less compared to vancomycin. Additionally, in patients with vancomycin MIC ≥ 2mcg/mL linezolid is preferred. Linezolid resistance and failure are rare.
Side-effects of Linezolid
- Thrombocytopenia
- Gastrointestinal side-effects
- Renal dysfunction
Side-effects of vancomycin
- Renal toxicity were more common in vancomycin compared to linezolid
Vancomycin trough
Supportive trial data [4]
In a study done in 1184 patients treated with linezolid and vancomycin no significant difference in 60 days mortality were found between the two groups. The side-effects profile were similar in both the groups however nephrotoxicity was commoner in the vancomycin group. Linezolid was found to be non-inferior to vancomycin for clinical outcome, and microbiologic outcome at end of treatment and end of study.
Methicillin sensitive staphylococcus aureus
- If the culture grows methicillin sensitive staphylococcus aureus then empiric treatment for MRSA should be stopped and MSSA agents such as nafcillin (2g iv Q4hrly) or oxacillin (2g iv Q4hrly) should be started.
Gram negative pathogen
- There is a lack of consensus regarding the choice of antibiotics for gram negative pathogens in ventilator associated pneumonia, and health care associated pneumonia.
- Large randomized clinical trials regarding the choice of anti-microbial agents in these conditions are lacking.
- Many hospitals prefer combination drug therapy over monotherpy in these conditions. The rationale behind these are:
- Wide coverage of pathogenic strains
- Avoidance of development of antibiotic resistant strains.
- In ICU settings cephalosporins should be avoided as monotherapy, due to problems of developments of resistant organism.
- The preferred agants in ICU settings are: carbapenem (ertapenem, meropenem, doripenem, and imipenem-cilastatin).
Legionella
At risk population
- Diabetes mellitus
- Chronic renal insufficiency
- Pulmonary diseases
- Glucocorticoids
- Hospitals with water supplies infected with legionella
Anti-microbial agents
Anaerobes
Antimicrobial agents
- Clindamycin
- A beta-lactam-beta-lactamase inhibitor combination
- Carbapenem
References
- ↑ 1.0 1.1 "Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia". American Journal of Respiratory and Critical Care Medicine. 171 (4): 388–416. 2005. doi:10.1164/rccm.200405-644ST. PMID 15699079. Retrieved 2012-09-12. Unknown parameter
|month=ignored (help) - ↑ Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, Kaplan SL, Karchmer AW, Levine DP, Murray BE, J Rybak M, Talan DA, Chambers HF (2011). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America. 52 (3): e18–55. doi:10.1093/cid/ciq146. PMID 21208910. Retrieved 2012-09-11. Unknown parameter
|month=ignored (help) - ↑ Rybak MJ, Lomaestro BM, Rotschafer JC, Moellering RC, Craig WA, Billeter M, Dalovisio JR, Levine DP (2009). "Vancomycin therapeutic guidelines: a summary of consensus recommendations from the infectious diseases Society of America, the American Society of Health-System Pharmacists, and the Society of Infectious Diseases Pharmacists". Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America. 49 (3): 325–7. doi:10.1086/600877. PMID 19569969. Retrieved 2012-09-11. Unknown parameter
|month=ignored (help) - ↑ Wunderink RG, Niederman MS, Kollef MH, Shorr AF, Kunkel MJ, Baruch A, McGee WT, Reisman A, Chastre J (2012). "Linezolid in methicillin-resistant Staphylococcus aureus nosocomial pneumonia: a randomized, controlled study". Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America. 54 (5): 621–9. doi:10.1093/cid/cir895. PMID 22247123. Retrieved 2012-09-11. Unknown parameter
|month=ignored (help)