Diagnosis

Common

Pathogens

Drug(s) of

First Choice1

Alternative

Drug(s)1

Comments

PNEUMONIA, HEALTHCARE-ASSOCIATED

Healthcare –associated pneumonia (HCAP): acquired in long-term care facility where antimicrobials used or Pseudomonas risk factors (see Comments)

 

 

 

 

 

 

 

 

Staph. aureus

S.pneumoniae

H.influenzae

 

Antibiotic sensitive enteric gram negative bacilli:

E. coli

Enterobacter

Klebsiella

Proteus

Serratia

Pseudomonas (if risk factors present)

Hemodynamically stable & no Pseudomonas risk factors

Vancomycin

Plus one of:

Ertapenem 1 gram IV daily

(WITH OR WITHOUT*:

Doxycycline 100mg IV/PO BID)

OR

Levofloxacin5 750mg IV/PO daily

 

Hemodynamically unstable or Pseudomonas risk factors

Vancomycin

Plus one of:

Piperacillin/

Tazobactam6 (Zosyn) 4.5 g IV q6h  

OR

Cefepime5 2g IV Q8-12H

ALL WITH OR WITHOUT*:

Azithromycin 500mg IV daily

 

For severe PCN allergy3:

Vancomycin2  

Plus

Aztreonam,6 2gm IV q8h

 

WITH OR WITHOUT*:

Doxycycline 100mg IV/PO BID

OR

Azithromycin 500mg IV daily

 

Pseudomonas risk factors include: structural lung disease, repeated exacerbations of severe COPD leading to frequent steroid and/or antibiotic use, recent mechanical ventilation, recent prior exposure to broad-spectrum antibiotics

 

Avoid using levofloxacin if the patient has recently been treated with a fluoroquinolone

 

*For patients admitted from the community with HCAP and not treated with levofloxacin, consider  adding atypical coverage with doxycycline (floor patients) or azithromycin (ICU patients)

Hospital-acquired pneumonia (including ventilator-associated) – EARLY ONSET

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

 

Staph. aureus

S.pneumoniae

H.influenzae

 

Antibiotic sensitive enteric gram negative bacilli:

E. coli

Enterobacter

Klebsiella

Proteus

Serratia

Vancomycin2

Plus one of:

Levofloxacin5 750 mg IV daily

OR

Ertapenem 1 gram IV daily

 

 

 

 

Mini-BAL recommended at UCSF

 

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

 

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

 

 

 

Hospital-acquired pneumonia – LATE ONSET

(including ventilator-associated)

(≥ 5 days of hospitalization or risk factors for resistant organisms*)

 

 

 

E. coli

Enterobacter

P. aeruginosa

Klebsiella

Staph. aureus

Vancomycin2

Plus one of:

Piperacillin/

Tazobactam6 (Zosyn) 4.5 g IV q6h  

OR

Cefepime5 2g IV Q8-12H

 

Alternatively:

Vancomycin2

Plus

Meropenem5 1-2g IV q8h (SFVAMC Imipenem5 500mg IV q6-8h  )

 

ALL WITH OR WITHOUT**:

Tobramycin2

For severe PCN allergy3:

Vancomycin2  

Plus

Aztreonam6 2gm IV q8h

 

Vancomycin2  

Plus

Tobramycin2

And

Aztreonam6 2g IV q8h

 

Mini-BAL recommended at UCSF

 

 

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

 

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