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10 Treatment Table 3. Empiric Treatment Options for Suspected MRSA/Pseudomonas/Gram-negative VAP A B C Gram-Positive Antibiotics With MRSA Activity Gram-Negative Antibiotics With Antipseudomonal Activity: β-Lactam–Based Agents Gram-Negative Antibiotics With Antipseudomonal Activity: Non-β-Lactam–Based Agents Glycopeptides a Antipseudomonal penicillins b Fluoroquinolones Vancomycin 15 mg/kg IV q8–12h (consider a loading dose of 25–30 mg/kg × 1 for severe illness) Piperacillin-tazobactam 4.5 g IV q6h b • Ciprofloxacin 400 mg IV q8h • Levofloxacin 750 mg IV q24h OR OR OR Oxazolidinones Cephalosporins b Aminoglycosides a, c Linezolid 600 mg IV q12h • Cefepime 2 g IV q8h • Amikacin 15–20 mg/kg IV q24h • Ceftazidime 2 g IV q8h • Gentamicin 5–7 mg/kg IV q24h • Tobramycin 5–7 mg/kg IV q24h OR OR Carbapenems b Polymyxins a,e • Imipenem 500 mg IV q6h d • Colistin 5 mg/kg IV × 1 (loading dose) followed by 2.5 mg × (1.5 × CrCl + 30) IV daily, divided q12h (maintenance dose) • Meropenem 1 g IV q8h OR Monobactams f • Polymyxin B 2.5–3.0 mg/kg/d divided in 2 daily IV doses Aztreonam 2 g IV q8h Choose one Gram-positive option from column A, one Gram-negative option from column B, and one Gram-negative option from column C. Note that the initial doses suggested in this table may need to be modified for patients with hepatic or renal dysfunction. a Drug levels and adjustment of doses and/or intervals required. b Extended infusions may be appropriate. Please see Optimization section. c On meta-analysis, aminoglycoside regimens were associated with lower clinical response rates with no differences in mortality. d e dose may need to be lowered in patients weighing <70 kg to prevent seizures. e Polymyxins should be reserved for settings where there is a high prevalence of multidrug resistance and local expertise in using this medication. Dosing is based on colistin-base activity (CBA) — for example, one million IU of colistin is equivalent to about 30 mg of CBA, which corresponds to about 80 mg of the prodrug colistimethate. Polymyxin B (1 mg = 10,000 units). 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.