A 77-year-old woman with chronic obstructive pulmonary disease is brought from her skilled nursing facility to the emergency room with fever and mixed hypoxemic-hypercarbic respiratory failure. She was last hospitalized 4 months ago for a hip fracture and last received antibiotics during that hospitalization. She has no known history of multidrug resistant infections, and no risk factors for methicillin-resistant Staphylococcus aureus infection. Chest X-ray demonstrates a right middle lobe infiltrate, and she is admitted to the intensive care unit for hypoxemia.
What is the MOST appropriate antibiotic choice and duration for her pneumonia?
A. Piperacillin-tazobactam for 5 to 7 daysCorrect Answer: D
In 2016, the category of healthcare-associated pneumonia was eliminated from the American Thoracic Society and Infectious Diseases Society of America guidelines, as it was thought to be overly sensitive and lead to increased, inappropriately broad, antibiotic use. The 2016 guidelines include the categories of community-acquired pneumonia (CAP), hospitalacquired pneumonia (HAP), and ventilator-associated pneumonia. The HAP category is reserved for patients who develop pneumonia at least 48 hours into hospitalization. Antibiotic choices for answers A, B, and C above are appropriate selections for HAP, although the recommended duration is generally 7 to 8 days, if the patient demonstrates sufficient clinical improvement on therapy. The patient in this scenario does not meet criteria for HAP and should be treated in a similar fashion to a patient with CAP admitted to the intensive care unit, accounting for additional risk factors. Residing in a skilled nursing facility is a risk factor for Pseudomonas pneumonia, and two antipseudomonal antibiotics are recommended as initial therapy. The duration of therapy can be tailored to clinical course, but no less than 5 days’ and no more than 10 days’ therapy is generally recommended.
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