Pharmacologic Therapy for Hcaphapvap

Nosocomial pneumonia was the term used to describe patients who develop pneumonia in an institutional setting but it has been replaced by the terms health care-associated pneumonia, hospital-associated pneumonia, and VAP. Empirical selection of antimicrobial therapy for ventilator-, health care-, and hospital-associ-atedpneumonia is broad spectrum; however, once culture and susceptibility information are available, the therapy should be narrowed (de-escalation) to cover the identified pathogen(s). Two factors important to the empirical selection of antibiotics for these types of pneumonia are onset time after admission and risk factors for MDR organisms. If it is early onset (less than or equal to 5 days since admission) and there are no risk factors for MDR organisms then the most frequent pathogens include S. pneumoniae, H. influenzae, methicillin-susceptible Staphylococcus aureus (MSSA), and enteric gram-negative bacilli. Recommendations for therapy include third-generation cephalosporins such as ceftriaxone or cefotaxime, a respiratory fluoroquinolone such as gemifloxacin, levofloxacin, or moxifloxacin; or ampicillin/sulbactam or er-31

tapenem. If it is late-onset pneumonia and/or there are risk factors for MDR organisms, then the pathogen list includes P aeruginosa, extended-spectrum ^-lactamase producing K. pneumoniae, Acinetobacter spp., and MRSA. Empirical antibiotic selection must cover P aeruginosa, which often then covers the other gram-negative pathogens. Available antibiotics include cefepime, ceftazidime, imipenem, meropenem, piperacillin/tazobactam, ticarcillin/clavulanate, levofloxacin, ciprofloxacin, gentamicin, tobramycin, and amikacin. Empirical therapy for late onset (listed in Table 71-5) could include any of the ^-lactams, carbapenems, or fluoroquinolones alone or in combination with one of the aminoglycosides. If MRSA is suspected then either vancomycin or linezolid should be added to the regimen. Recommendations for vancomycin trough concentrations of 15 to 20 mcg/mL were based on expert opinion

not evidence from clinical trials.

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