New GLA pneumonia guidelines!

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Based on recent guidelines from the Infectious Diseases Society of America, the Antimicrobial Stewardship Program and Infectious Diseases Section at GLA have revised our local guidelines for management of pneumonia and updated our order sets (both for Inpatient Antibiotic Protocols and Outpatient Antibiotic Protocols).  

The full guidelines are attached and also available at http://www.vaglaid.org/gla-guidelines.

Main takeaway points:

  • The Pneumonia Severity Index can be used in making a decision as to whether a patient with pneumonia is best served in an inpatient vs. outpatient setting: https://www.mdcalc.com/psi-port-score-pneumonia-severity-index-cap (link provided in order sets)

  • Once a patient is admitted, the following criteria can be used to determine pneumonia severity (which has an impact on antimicrobial selection). Severe inpatient pneumonia can be defined by meeting either one major or three or more minor criteria:

    • Major criteria

      • Septic shock requiring vasopressors

      • Respiratory failure requiring mechanical ventilation

    • Minor criteria

      • Respiratory rate ≥ 30 breaths/min

      • PaO2/FiO2 ratio ≤ 250

      • Multilobar infiltrates

      • Confusion/disorientation

      • Azotemia (BUN > 20mg/dL)

      • Leukopenia (WBC < 4000 cells/µL)

      • Thrombocytopenia (platelets < 100,000/ µL)

      • Hypothermia (core temperature < 36°C)

      • Hypotension requiring aggressive fluid resuscitation

  • “Healthcare-associated pneumonia” (aka “HCAP”) is no longer a recognized distinct clinical entity. Risk factors for MRSA and resistant-Gram negative bacteria as pathogens in community-acquired pneumonia and ward-onset hospital acquired pneumonia should be assessed on an individual basis.

    • Risk factors for which MRSA coverage should be considered in CAP and ward-onset HAP:

      • Isolation of MRSA from respiratory culture/nares within the past year

      • Severe disease per criteria above

    • Risk factors for which broadened Gram-negative coverage should be considered in CAP and ward-onset HAP:

      • Isolation of ceftriaxone-resistant Gram-negative rods from respiratory cultures within the past year

      • Receipt of broad-spectrum Gram-negative therapy in the past 90 days

      • Residence in skilled nursing facility (relative indication)

  • Most community-acquired pneumonia can be treated with 5 total days of therapy, and most hospital-acquired pneumonia can be treated with 7 total days of therapy.