Hospital Acquired Pneumonia (HCAP) and Community Acquired Pneumonia (CAP) Antibiotic orders

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Pneumonia Severity Index
Risk Class Score Mortality
Low I < 51 0.1%
Low II 51 - 70 0.6%
Low III 71 - 90 0.9%
Medium IV 90 - 130 9.5%
High V > 130 26.7%
Hospitalization is recommended for class IV and V.
Class III should be based on clinical judgment.
Select based upon Severity score and criteria below

Health Care Associated Pneumonia (HCAP)
Healthcare-associated pneumonia (HCAP) is defined as pneumonia that occurs in a non- hospitalized patient with extensive healthcare contact as
defined by one or more of the following
Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days
Residence in a nursing home or other long-term care facility
Hospitalization in an acute care hospital for two or more days within the prior 90 days
* Attendance at a hospital or hemodialysis clinic within the prior 30 days
Non-ICU - CAP with risk factors for Multidrug Resistant Pathogens and Pseudomonas **
Non-ICU - CAP with risk factors for Multidrug Resistant Pathogens and Pseudomonas ** - Severe PCN allergy
**Risk factors for Pseudomonal Pneumonia
1. immunocompromised individuals (eg, HIV-infected patients, solid organ or hematopoietic cell transplant recipients, or neutropenic hosts)
2. recent prior antibiotic use
3. structural lung abnormalities such as cystic fibrosis, bronchiectasis, or repeated exacerbations of COPD requiring frequent glucocorticoid and/or antibiotic use
4. history of recent hospitalization
5. intubation or enteral tube feeding
* Risk factors for Multidrug Resistant Pathogens:
1. Antimicrobial therapy in preceding 90 days
2. Current hospitalization of 5 days or more
3. High frequency of antibiotic resistance in the community or in the specific hospital unit
Prior History of MDR
Non-ICU -CAP with no known risk factors for Multidrug Resistant pathogens* and Pseudomonas**
ICU CAP: ICU CAP Severe PCN allergic:
ICU - CAP Antipneumococcal / Antipseudomonal * ICU - CAP Antipneumococcal / Antipseudomonal * Severe PCN allergic:
Aspiration pneumonia


Hospital Acquired Pneumonia (HCAP) and Community Acquired Pneumonia (CAP) Antibiotic orders
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Non-ICU -CAP with no known risk factors for Multidrug Resistant pathogens * & Pseudomonas
Ceftriaxone 1 gm IV x 1 dose + Azithromycin 500 mg IV x 1 dose

OR

Levofloxacin 750 mg IV x 1 dose
Note: If < 65 with no risk for Drug Resistant Pneumococcus : Azithromycin alone
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Hospital Acquired Pneumonia (HCAP) and Community Acquired Pneumonia (CAP) Antibiotic orders
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Non-ICU - CAP with risks for Multidrug Resistant pathogens * & Pseudomonas**
2 drug
regimen
Cefepime 1 gm IV X 1 dose
PLUS LevOFLOXACIN: 750 mg IV x 1 dose
OR
Piperacillin/Tazobactam 3.375gm IV X 1 dose
OR
3 drug
Regimen
Cefepime 1 gm IV X 1 dose
PLUS
LevOFLOXACIN: 750 mg IV x 1 dose
PLUS
Tobramycin
OR OR 6 mg/kg IV
Piperacillin/Tazobactam 3.375gm IV X 1 dose Azithromycin 500 mg IV x 1 dose x 1 dose
Note: If CA-MRSA is a consideration, add Vancomycin or Linezolid
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Hospital Acquired Pneumonia (HCAP) and Community Acquired Pneumonia (CAP) Antibiotic orders
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Non-ICU - CAP with Pseudomonal Risk * Severe PCN allergy
Aztreonam IV 1 gm x 1 dose PLUS LevOFLOXACIN: 750 mg IV x 1 dose
Plus
Consider Tobramycin if clinically indicated @ 6 mg/kg IV x 1 dose
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Hospital Acquired Pneumonia (HCAP) and Community Acquired Pneumonia (CAP) Antibiotic orders
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ICU - CAP(with NO Risks for MDR & Pseudomonas* *):

Ceftriaxone 1 gm IV x 1 dose
PLUS Azithromycin 500 mg IV x 1 dose
OR
Cefepime 1 gm IV X 1 dose
OR
Piperacillin/Tazobactam 3.375gm IV X 1 dose
OR

Ceftriaxone 1 gm IV x1dose
PLUS LevOFLOXACIN: 750 mg IV x 1 dose
OR
Cefepime 1 gm IV X 1 dose
OR
Piperacillin/Tazobactam 3.375gm IV X 1 dose
Note: If CA-MRSA is a consideration, add Vancomycin or Linezolid
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Hospital Acquired Pneumonia (HCAP) and Community Acquired Pneumonia (CAP) Antibiotic orders
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ICU CAP Severe PCN allergic:
Aztreonam IV 1 gm x 1 dose PLUS LevOFLOXACIN: 750 mg IV x 1 dose
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Hospital Acquired Pneumonia (HCAP) and Community Acquired Pneumonia (CAP) Antibiotic orders
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ICU - CAP Regimens (with Risks for MDR *& Pseudomonas * *):

2 drug regimen
Cefepime 1 gm IV x 1 dose
Plus LevOFLOXACIN: 750 mg IV x 1 dose
Piperacillin/Tazobactam 3.375gm IV X 1 dose
OR
3 drug regimen
Cefepime 1 gm IV x 1 dose
Plus
Tobramycin 6mg/kg
IV x 1 dose
Plus
LevOFLOXACIN: 750 mg IV x 1 dose
OR
Piperacillin/Tazobactam 3.375gm IV x 1 dose or
OR
Azithromycin 500 mg IV 1dose
Meropenem 500 mg IV x 1 dose
Note: If CA-MRSA is a consideration, add Vancomycin or Linezolid
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Hospital Acquired Pneumonia (HCAP) and Community Acquired Pneumonia (CAP) Antibiotic orders
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ICU - CAP Antipneumococcal / Antipseudomonal * Regimens Severe PCN allergic:
Aztreonam IV 1 gm x 1 dose PLUS LevOFLOXACIN: 750 mg IV x 1 dose
or
Aztreonam IV 1 gm x 1 dose + Tobramycin 6mg/kg IV x 1 dose + Azithromycin IV/PO 500 mg x 1 dose
If suspect MRSA
Vancomycin Dose: 20 mg/kg IV x 1 dose round to nearest 250 mg, doses of 500,750,1000,1250,1500,1750, 2000mg
OR
Linezolid 600 mg IV x 1 dose
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Hospital Acquired Pneumonia (HCAP) and Community Acquired Pneumonia (CAP) Antibiotic orders
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Health Care Associated Pneumonia (HCAP)
Please choose your antibiotic/antibiotics for HCAP
Consider based on severity of pneumonia and the risk factors For MDR and Functional status.
Ceftriaxone 1 gm IV daily x 7days
Azithromycin 500 mg IV daily x 7days
Aztreonam Use for Severe PCN allergic:
CrCl of >= 30 mL/min 1gm IV Q8hrs X 7 days
CrCl of 10-30 mL/min 500mg IV Q8hrs X 7 days
CrCl of < 10 mL/min 250mg IV Q8hrs X 7 days
levofloxacin (Levaquin)
CrCl of >= 50 mL/min 750mg IV Q24hrs X 5 days
CrCl of 20- 49 mL/min 750mg IV Q48hrs X 3 doses
CrCl of < 20 mL/min; 750mg IV X 1 dose then 500mg IV Q48hrs X 2 doses
HD: 500mg IV Q48hrsX 3 doses
Meropenem
CrCl of > 50 L/min 500mg IV Q6hrs X 7 days
CrCl of 26-50 mL/min 500 gm IV Q 8 hrs X 7 days
CrCl of 10-25 mL/min 500 mg IV Q 12 hrs X 7 days
CrCl of < 10 mL/min 500 mg IV q 24 hrs X 7 days
If Pseudomonas suspected or confirmed

cefepime (Maxipime) 2 gm x1dose
CrCl of >60 mL/min 1gm IV Q12hrs X 7 days
CrCl of 30-60 mL/min 1gm IV Q24hrs X 7 days
CrCl of 11-29 mL/min 500 mg IV Q24hrs X 7 days
CrCl of < 11 mL/min 250 mg IV Q24hrs X 7 days
for HD 500 mg IV Q24hrs X 7 days
plus
levofloxacin (Levaquin)
CrCl of >= 50 mL/min 750mg IV Q24hrs X 5 days
CrCl of 20- 49 mL/min 750mg IV Q48hrs X 3 doses
CrCl of < 20 mL/min; 750mg IV X 1 dose then 500mg IV Q48hrs X 2 doses
HD: 500mg IV Q48hrsX 3 doses
or

piperacillin-tazobactam (Zosyn)
CrCl of >40 mL/min 3.375 gms IV Q6 hrs X 7 days
CrCl of 20-40 mL/min 2.25 gms IV Q 6 hrs X 7 days
CrCl of < 20 mL/min 2.25 gms IV Q 8 hrs X 7 days
2.25 gm q 12 hrs X 7 days
after each HD 0.75gm after each HD
plus
levofloxacin (Levaquin)
CrCl of >= 50 mL/min 750mg IV Q24hrs X 5 days
CrCl of 20- 49 mL/min 750mg IV Q48hrs X 3 doses
CrCl of < 20 mL/min; 750mg IV X 1 dose then 500mg IV Q48hrs X 2 doses
HD: 500mg IV Q48hrsX 3 doses
**Optional if needed** tobramycin 6 mg/kg IV x 1; then pharmacy to dose
If suspect MRSA
Vancomycin Dose: 20 mg/kg IV x 1 dose round to nearest 250 mg, doses of 500,750,1000,1250,1500,1750, 2000mg
OR
Linezolid 600 mg IV x 1 dose
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Hospital Acquired Pneumonia (HCAP) and Community Acquired Pneumonia (CAP) Antibiotic orders
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Aspiration pneumonia
If Acquired in Outpatient: clindamycin (Cleocin) 600 mg IV every 8 hours
Plus
Ampicillin-sulbactam 3 gm IV q 6 hrs
Crcl >30: 1.5-3.0 grams q6-8h
Crcl 15-30]: 1.5-3.0 grams q12h
Crcl 5-14 : 1.5-3.0 grams q24 hours
HD 1.5 - 3.0 grams q24 hours give dose after dialysis when patient is
being dialyzed
If Acquired Inpatient (transfers, etc): piperacillin-tazobactam (Zosyn) 4.5 gm IV every 6 hours (see above for renal)
PLUS
vancomycin (see above dosing) for goal trough of 15-20
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