American Thoracic Society Quick-Reference GUIDELINES Apps
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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.