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CHAPTER 65: Pneumonia 587

Specific Therapy: Once the etiologic diagnosis is known, specific An important distinction in prevention is that strategies to decrease
antibiotic choices become much more straightforward. Some pneu- pneumonia may be slightly different than strategies to decrease the risk
monias require treatment with antibiotics outside the usual spectrum of pneumonia due to MDR pathogens. Clearly the most important issue
of empirical agents, including trimethoprim/sulfamethoxazole for for the latter is minimization of antibiotic exposure. Emergence of resis-
Stenotrophomonas maltophilia, ampicillin/sulbactam for Acinetobacter tance is most dependent on duration of therapy. Therefore, appropriate
sp, or colistin for KPC-carrying Enterobacteriaceae. However, specific discontinuation of prophylactic perioperative and other antibiotics is
treatment for several pathogens remains controversial. very important. In addition, use of broad-spectrum antibiotics and
Recommended treatment for MRSA pneumonia is either linezolid combination antibiotic therapy also increase the risk.
94
or glycopeptides, usually vancomycin. Subgroup analysis of FDA-
registration trials and a head-to-head comparison suggest that clinical
111
outcome is improved with linezolid compared to vancomycin, even with
high dose adjusted therapy. This difference is probably less important KEY REFERENCES
112
in patients with HAP who never required ICU admission than in ICU • Azoulay E, Alberti C, Bornstain C, et al. Improved survival in
pneumonias, particularly those with VAP. 111 cancer patients requiring mechanical ventilatory support: impact
The need for combination therapy for Pseudomonas once the isolate of noninvasive mechanical ventilatory support. Crit Care Med.
is known to be sensitive to a β-lactam also remains unclear. No large 2001;29(3):519-525.
RCT has been performed and smaller ones do not demonstrate a benefit.
However, the clinical outcome for Pseudomonas pneumonia remains so • Blot S, Koulenti D, Dimopoulos G, et al. Prevalence, risk factors,
poor that adjunctive therapy seems warranted. and mortality for ventilator-associated pneumonia in middle-
aged, old, and very old critically ill patients. Crit Care Med.
Optimized Pharmacokinetics/Pharmacodynamics: Because HAP is a 2014;42(3):601-609.
potentially life-threatening illness, antibiotic dosing should be • Bouadma L, Luyt CE, Tubach F, et al. Use of procalcitonin to
optimized for maximal effect. This usually involves using the high- reduce patients’ exposure to antibiotics in intensive care units
est recommended dose. Beta lactams should be given as prolonged (PRORATA trial): a multicentre randomised controlled trial.
infusions in order to maximize their time above the minimal inhibi- Lancet. 2010;375(9713):463-474.
tory concentration. The aminoglycosides should be given as a single
daily dose to maximize the area under the inhibitory curve and take • Chastre J, Wolff M, Fagon JY, et al. Comparison of 8 vs 15 days of
advantage of their post-antibiotic effects. Vancomycin dosing is antibiotic therapy for ventilator-associated pneumonia in adults: a
much more controversial. Dosing adjusted to achieve vancomycin randomized trial. JAMA. 2003;290(19):2588-2598.
trough levels in the 15 to 20 µg/mL range has been associated with • Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify
increased nephrotoxicity and no clear-cut improvement in clinical low-risk patients with community-acquired pneumonia. N Engl J
response. 112 Med. 1997;336(4):243-250.
HAP is unlikely to need a longer duration of therapy than VAP. • Halm EA, Fine MJ, Kapoor WN, Singer DE, Marrie TJ, Siu AL.
113
Therefore, 7 to 8 days is adequate in the majority of cases. For Instability on hospital discharge and the risk of adverse out-
Pseudomonas, the requirement for duration longer than 8 days probably comes in patients with pneumonia. Arch Intern Med. 2002;162(11):
represents ineffective treatment—alternative therapy, rather than pro- 1278-1284.
longing use of the same antibiotics, may lead to better outcomes. Once
again, appropriate de-escalation based on culture results is critical to • Kett D, Cano E, Quartin A, et al. Implementation of guidelines for
management of possible multidrug-resistant pneumonia in inten-
avoid toxicity and decrease the selective pressure for antibiotic-resistant
strains. 107,113 sive care: an observational, multicentre cohort study. Lancet Infect
Dis. 2011;11(3):181-189.
■ PREVENTION • Maclaren R, Reynolds PM, Allen RR. Histamine-2 receptor
Prevention of HAP has received significantly less attention recently antagonists vs proton pump inhibitors on gastrointestinal tract
than prevention of VAP. Since many of the strategies for VAP prevention hemorrhage and infectious complications in the intensive care
unit. JAMA Intern Med. 2014;174(4):564-574.
are predicated on the presence of an endotracheal tube, most are inap-
propriate for HAP. Potential strategies to decrease the risk of HAP are • Renaud B, Santin A, Coma E, et al. Association between timing of
listed in Table 65-9. intensive care unit admission and outcomes for emergency depart-
ment patients with community-acquired pneumonia. Crit Care
Med. 2009;37(11):2867-2874.
TABLE 65-9 Strategies to Prevent Hospital-Acquired Pneumonia • Whitney CG, Farley MM, Hadler J, et al. Decline in invasive pneu-
mococcal disease after the introduction of protein-polysaccharide
Minimize excess antibiotics
conjugate vaccine. N Engl J Med. 2003;348(18):1737-1746.
Short-course surgical prophylaxis • Wunderink RG, Niederman MS, Kollef MH, et al. Linezolid
Cough and deep breathing/incentive spirometry in methicillin-resistant Staphylococcus aureus nosocomial
Increase mobility as soon as possible pneumonia: a randomized, controlled study. Clin Infect Dis.
2012;54(5):621-629.
Heightened awareness of aspiration risk
• Yende S, D’Angelo G, Kellum JA, et al. Inflammatory markers
Appropriate analgesia
at hospital discharge predict subsequent mortality after pneu-
Adequate for good cough/deep breath monia and sepsis. Am J Respir Crit Care Med. 2008;177(11):
Avoid oversedation and decreased level of consciousness 1242-1247.
Avoid unnecessary H -blockers and proton-pump inhibitors
2
Minimize use of nasogastric tube
Appropriate infection control of respiratory therapy equipment REFERENCES
Hand hygiene
Complete references available online at www.mhprofessional.com/hall

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