104: Updated IDSA HAP / VAP Guidelines

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In this episode I’ll discuss highlights from the new IDSA/ATS HAP/VAP guidelines.

The guidelines were published July 14, 2016 and are titled:

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

General information

These guidelines went 11 years between updates. Three major differences between the 2005 and 2016 guidelines are:

1. Adoption of the GRADE methodology for the evaluation of all available evidence.
2. The removal of the concept of healthcare-associated pneumonia (HCAP).
3. A greater emphasis on local antibiograms altering the choice of empiric antibiotic therapy.

The panel unanimously agreed to remove the concept of HCAP from the guidelines. The main reason for the removal of HCAP is that contact with the healthcare system is not a good predictor of risk for multi-drug resistant (MDR) bacteria.

Local antibiograms and ICU-specific antibiograms are heavily emphasized throughout the guidelines.

The guidelines are specifically meant for application in nonimmunocompromised patients. The opportunistic pulmonary infections that immunocompromised patients are at risk for are not addressed.

Biomarkers

The guideline authors address the use of biomarkers such as procalcitonin, C-reactive protein, and the Clinical
Pulmonary Infection Score (CPIS).

The guidelines recommend not using any biomarkers to make the decision to initiate antibiotic therapy for HAP or VAP, and to rely on clinical criteria alone.

The guidelines provide a weak recommendation for the use of procalcitonin levels plus clinical criteria to make the decision on whether to discontinue antibiotic therapy in patients with HAP/VAP. One reason for the weak recommendation is that the control groups in the studies identified had antibiotic durations of 9 to 15 days. With the guideline recommendations for 7 days of therapy for HAP/VAP, it is unclear whether procalcitonin levels would be of benefit for deciding to stop antibiotics before 7 days is up.

Risk factors for multidrug-resistant (MDR) pathogens

Prior intravenous antibiotic use within 90 days is considered a risk factor for MDR including MDR psuedomonas in VAP or HAP. Prior intravenous antibiotic use within 90 days is also a risk factor for MRSA in VAP or HAP.

Beyond prior intravenous antibiotic use within 90 days, there are additional risk factors for MDR in VAP only:

– Septic shock at time of VAP
– ARDS preceding VAP
– Five or more days of hospitalization prior to the occurrence of VAP
– Acute renal replacement therapy prior to VAP onset

VAP treatment

MRSA coverage is suggested in VAP for patients with a risk factor for antibiotic resistance, or if the unit the patient is being treated in has more than a 10 to 20 % prevalence of MRSA among all staph aureus isolates. If the prevalence of MRSA is unknown it should be assumed to be high.

The guidelines give equal weight to the use of vancomycin and linezolid for MRSA coverage in VAP. The guideline authors suggest:

The choice between vancomycin and linezolid may be guided by patient-specific factors such as blood cell counts, concurrent prescriptions for serotonin-reuptake inhibitors, renal function, and cost.

The guidelines suggest prescribing 2 antipseudomonal antibiotics from different classes if the patient with VAP has risks for MDR or if more than 10% of the isolates in the unit are resistant to the choice of antipseudomonal antibiotic. Again if the prevalence of antibiotic resistance is unknown it should be assumed to be high. If patient has structural lung disease (bronchiectasis or cystic fibrosis), 2 antipseudomonal agents are recommended.

The guidelines recommend avoiding aminoglycosides and colistin if possible.

HAP treatment

The authors add an additional decision point for deciding on empiric antibiotic treatment for patients with HAP: whether or not the patient is at high risk of mortality. The authors consider patients with ventilator support or septic shock due to HAP at high risk of mortality.

Patients with no MRSA risk and who are not at high risk of mortality need coverage for MSSA and 1 antipseudomonal agent.

Patients with MRSA risk and who are not at high risk of mortality need coverage for MRSA and 1 antipseudomonal agent.

Patients with MRSA risk and who are at high risk of mortality need coverage for MRSA and 2 antipseudomonal agents.

Duration of therapy

The duration of therapy for VAP and HAP is strongly recommended to be 7 days.

Pharmacodynamic/pharmacokinetic optimization of antibiotic therapy

The authors give a weak recommendation that:

For patients with HAP/VAP, we suggest that antibiotic dosing be determined using PK/PD data, rather than the manufacturer’s prescribing information.

In the context of the guidelines, PK/PD-optimized dosing refers to the use of antibiotic blood concentrations, extended and continuous infusions, and weight-based dosing for certain antibiotics.

Discussion

I hope the removal of HCAP, the emphasis on local antibiograms, and the recommendation to use PK/PD data rather than manufacturer’s prescribing information provides some breathing room from CMS quality measures to allow for common sense and good clinical care to prevail.

My hospital does not have an ICU specific antibiogram.  We have three adult ICUs with 8, 10, and 19 beds.  It will be interesting to see if we can get a meaningful number of pseudomonas isolates to develop unit-specific guidance for when to use 2 antipseudomonal agents for HAP or VAP.

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