9
High Risk of Mortality or Receipt of Intravenous
Antibiotics During the Prior 90 d
a,c
Two of the following (avoid two β-lactams):
Piperacillin-tazobactam
d
4.5 g IV q6h OR
Cefepime or ceazidime
d
2 g IV q8h
d
• Levofloxacin 750 mg daily OR
• Ciprofloxacin 400 mg IV q8h
• Imipenem
d, e
500 mg IV q6h OR
• Meropenem
d
1 g IV q8h
• Amikacin 15–20 mg/kg IV daily OR
• Gentamicin 5–7 mg/kg IV daily OR
• Tobramycin 5–7 mg/kg IV daily OR
• Aztreonam
f
2 g IV q8h
Plus:
• Vancomycin 15 mg/kg IV q8–12h with goal to target 15–20 mg/mL trough level
(consider a loading dose of 25–30 mg/kg IV × 1 for severe illness) OR
• Linezolid 600 mg IV q12h
• If MRSA coverage is not going to be used, include coverage for MSSA.
Options include:
• Piperacillin-tazobactam, cefepime, levofloxacin, imipenem, meropenem.
• Oxacillin, nafcillin, and cefazolin are preferred for the treatment of proven MSSA,
but would ordinarily not be used in an empiric regimen for HAP.
If patient has severe penicillin allerg y and aztreonam is going to be used instead of any
β-lactam–based antibiotic, include coverage for MSSA.
c
If patient has factors increasing the likelihood of Gram-negative infection, 2 antipseudomonal
agents are recommended. If patient has structural lung disease increasing the risk of Gram-negative
infection — i.e., bronchiectasis or cystic fibrosis, two antipseudomonal agents are recommended.
A high-quality Gram stain from a respiratory specimen with numerous and predominant
Gram-negative bacilli provides further support for the diagnosis of a Gram-negative pneumonia,
including fermenting and non-glucose-fermenting microorganisms.
d
Extended infusions may be appropriate.
e
e dose may need to be lowered in patients weighing <70 kg to prevent seizures.
f
In the absence of other options, it is acceptable to use aztreonam as an adjunctive agent with
another β-lactam–based agent because it has different targets within the bacterial cell wall.