Spectrum: Local Antimicrobial Stewardship, for Prisma Health-Midlands

Community-Onset Pneumonia

Notes

Clinical Criteria

  • Radiographic infiltrate, AND

  • 2 of 3 clinical features:

    • Fever (>38ºC or >100.4ºF)
    • Leukocytosis or leukopenia
    • Purulent sputum

Type of Pneumonia

  • CAP: Symptom onset occurring in the community setting or <48hrs after hospital admission

  • HCAP: Use of this term is no longer recommended due to poor predictive performance for drug resistance

Diagnostics to Consider

  • CXR

  • Vitals

  • ABG/O₂ sat

  • CBC

  • Respiratory GS and culture

  • Blood culture x 2 sites

  • S. pneumoniae and Legionella urinary antigens

  • MRSA nasal swab for PCR

  • Influenza A & B PCR

Empiric Treatment Notes

  • All dosages provided assume normal renal and hepatic function

  • Use of clinical judgment is encouraged when selecting empiric therapy for a patient, including consideration of severity of illness, prior microbiology, and prior antimicrobial history (duration ≥48hrs, excludes one-time doses and/or most surgical prophylaxis)

  • Revise antimicrobial regimen based on microorganism identification (e.g. culture, PCR) and antimicrobial susceptibility testing results

Abbreviations

  • APBL: Antipseudomonal beta-lactam

  • AMC: Amoxicillin-clavulanate

  • FEP: Cefepime

  • CRO: Ceftriaxone

  • CAZ: Ceftazidime

  • TZP: Piperacillin-tazobactam

Empiric Treatment Recommendations

No Pathogen-Specific Risk Factors

Risk Factors for Antipseudomonal Beta-lactam (APBL)-Susceptible Pseudomonas aeruginosa

Risk factors include:

  • Interstitial lung disease (e.g. severe pulmonary fibrosis, but excluding COPD or asthma)

  • Prior use (duration ≥48 hrs, excludes one-time doses and/or most surgical prophylaxis) of non-APBL within last 3-30 days (e.g. AMC, CRO)

  • Prior airway colonization with P. aeruginosa susceptible to APBL (e.g. TZP, FEP, CAZ) within the last 12 months

  • Severe immune compromise:

    • Neutropenia (ANC <500 cells/mm³)
    • HIV/AIDS (CD4 <200 cells/mm³)
    • Immunocompromising medications within the last 30 days
    • High-dose corticosteroids of ≥20mg daily
    • Prednisone-equivalents ≥1 week
    • Chemotherapy
    • Calcineurin inhibitors

Risk Factors for Antipseudomonal Beta-lactam (APBL)-Resistant Pseudomonas aeruginosa

Risk factors include:

  • Cystic fibrosis or bronchiectasis

  • Prior APBL use for ≥48hrs within 3-30 days (e.g. TZP, FEP, CAZ). Excludes most surgical prophylaxis.

  • Prior airways colonization with P. aeruginosa resistant to APBL (e.g. TZP, FEP, CAZ) within the last 12 months

Aspiration Pneumonia

Beta-Lactam Allergy

Additional Information

Empiric Levofloxacin Use

  • Given the importance of fluoroquinolones in the management of serious infections and their relative toxicity (e.g. dysglycemias, CNS side effects, muscle injury, tendonitis) compared to alternative agents, it is recommended to reserve fluoroquinolones for select patient cases where benefit outweighs the risk (e.g. severe beta-lactam allergy, oral antipseudomonal coverage)

  • Avoid levofloxacin for gram-negative bacterial coverage if patient had prior fluoroquinolone use particularly within the past 3 months (risk of infections due to fluoroquinolone-resistant bacteria may persist for up to 12 months from fluoroquinolone use)

Renal Impairment

  • If tobramycin is recommended, consider replacing this agent with an antipseudomonal fluoroquinolone (i.e. ciprofloxacin or levofloxacin) in the absence of recent fluoroquinolone use within the past 3 months

  • Inhaled tobramycin may be considered in patients with renal impairment who received fluoroquinolones recently

MRSA Nasal Swab PCR

  • This test demonstrates a negative predictive value of >95% for ruling out MRSA as a causative pathogen for pneumonia

  • This is a useful diagnostic in patients at increased risk of MRSA pneumonia at baseline (e.g. residence in a long-term care facility, wound care in the last 30 days, prior MRSA infection/colonization within 90 days)

Respiratory Viral PCR Panel

  • This test, which is designed for upper respiratory tract infections, includes both viral and atypical bacterial targets for community-acquired pneumonia

  • If the patient is unlikely to have polymicrobial pneumonia, consider streamlining to appropriate viral pneumonia management (e.g. oseltamivir for influenza A or B virus, supportive care for rhinovirus) or atypical bacterial pneumonia management (e.g. azithromycin)

Additional Risk Factors for Antimicrobial Resistance

Extended-spectrum beta-lactamase producing organisms (ESBL):

  • Carbapenems are preferred in patients with high risk of pneumonia due to ESBL-producing bacteria, including:

    • Documentation of prior infections or colonization with ESBL-producing bacteria in the past 12 months
    • Receipt of multiple courses of broad-spectrum antibiotics (piperacillin-tazobactam, cefepime, etc.) in the past 90 days

Consult PHASST during business hours or an infectious diseases specialist for assistance determining optimal empirical antimicrobial therapy