CAP/HAP/VAP

Pneumonia: New lung infiltrate + clinical evidence that the infiltrate is infectious in origin
Indicators of Infectious Origin: new onset fever, purulent sputum, leukocytosis, declining oxygenation
Community Acquired Pneumonia
When a Respiratory/Blood Culture Should be Performed: Classification of Severe CAP: 1 major OR > 3 minor
• Hospitalized patients with severe CAP criteria
• Patients receiving empiric treatment for MRSA/Pseudomonas Major Criteria:
• Patients with a history of MRSA/Pseudomonas infection • Septic Shock requiring Vasopressors
• Previous hospitalization and IV Abx in the past 90 days • Respiratory Failure requiring Mechanical
Empiric Microbial Coverage: S. pneumoniae, M. catarrhalis, H. influenzae, C. Ventilation
pneumoniae, M. pneumoniae, Legionella sp. Minor Criteria:
Empiric Outpatient Treatment: Empiric Inpatient Treatment: • Respiratory Rate > 30 bpm
No Comorbidities/Risk Factors: Non-Severe: • PaO2/FiO2 Ratio < 250
• Amoxicillin 1g TID • β-Lactam + Macrolide • Multilobar Infiltrates
• Doxycycline 100mg BID • Respiratory Fluoroquinolone • Confusion/Disorientation
• Macrolide (if local pneumococcal Severe: • Uremia (BUN > 20 mg/dL)
resistance < 25%) • β-Lactam + Macrolide • Leukopenia (WBCs < 4000 cells/microliter)
With Comorbidities: • β-Lactam + Fluoroquinolone • Thrombocytopenia (Plt <
• Augmentin OR Cephalosporin + Adding MRSA/Pseudomonas Coverage: 100,000/microliter)
Macrolide OR doxycycline • Prior respiratory isolation • Hypothermia (Temp < 36 °C)
• Respiratory Fluoroquinolone • Recent hospitalization with IV • Hypotension requiring aggressive fluid
Monotherapy Abx* resuscitation
Adjunctive Therapies:
Corticosteroids: Not recommended in the setting of CAP except in the setting of refractory septic shock (per Surviving Sepsis Campaign)
Concomitant Influenza Infection: Anti-influenza treatment should be initiated in patients testing positive for influenza.
Duration of Therapy: > 5 days in addition to patient achieving clinical stability (Resolution of Vital Sign Abnormalities, Ability to Eat, Normal
Mentation); PCT: If < 0.25 ng/mL in patients who have clinically improved and received > 5 days of antibiotics, discontinuation of abx may be
considered.
Aspiration Pneumonia: Empiric anaerobic coverage is not recommended in the setting of aspiration pneumonia unless a lung abscess or
empyema is suspected.

Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia: An Official Clinical Practice
Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019; 200(7): e45-e67.
Kalil AC, Metersky ML, Klompas M, et al. Management of Adults with Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical
Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016; 63(5): e61-e111.
 Hospital Acquired Pneumonia/Ventilator-Associated Pneumonia
HAP VAP
Pneumonia occurring >48 hours after hospital admission. Pneumonia occurring >48 hours after endotracheal intubation.
MDR Risk Factors: MDR Risk Factors:
• IV Abx use in the past 90 days • IV Abx use in the past 90 days
• >5 days hospitalized prior to VAP
• Septic shock at the time of VAP
• ARDS prior to VAP
• RRT prior to VAP
MRSA/MDR Pseudomonas Risk Factor: IV Abx use in the past 90 days
Empiric Microbial Coverage: S. aureas, P. aeruginosa, Gram (-) Bacilli
When to Cover for MRSA: When to Use 2 vs. 1 Anti-Pseudomonal Antibiotics:
• IV Abx use in the past 90 days ⚫ MDR Risk Factor
• Unit with >10% S. aureus isolates being MRSA ⚫ ICU where antimicrobial susceptibility rates are unavailable
• Units where MRSA prevalence is unknown ⚫ Units with >10% Gram (-) isolate resistance to monotherapy
options
Recommended Empiric Coverage of MRSA: Vancomycin or Linezolid
Recommended Empiric Coverage of Pseudomonas: Anti-Pseudomonal Antibiotics; Not Aminoglycosides
Recommended Coverage for Specific Organisms:
• Acinetobacter: Carbapenem OR Ampicillin/Sulbactam OR Polymyxins
• Carbapenem-Resistant Organisms: Polymyxins
Duration of Therapy: 7 days
Pneumococcal Vaccination Recommendations
Age 65yo and Older: x1 dose PPSV23
• If a dose of PPSV23 was administered prior to the age of 65, administer x1 dose of PPSV23 at least 5 years after previous dose
Shared Clinical Decision-Making: x1 dose of PCV13
• If administering both PPSV23 and PCV13, administer PCV13 first followed by PPSV23 1 year later
Ages 19-64 with Chronic Medical Conditions: x1 dose of PPSV23
Immunocompromised Patients Age 19yo and Older: x1 dose of PCV13 followed by x1 dose of PPSV23 8 weeks later, then x1 dose of PPSV23
at least 5 years after previous PPSV23 dose; at age 65 administer x1 dose of PPSV23 at least 5 years after most recent PPSV23 dose.

Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia: An Official Clinical Practice
Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019; 200(7): e45-e67.
Kalil AC, Metersky ML, Klompas M, et al. Management of Adults with Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical
Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016; 63(5): e61-e111.