Approach to managing low- to moderate-severity HAP

Empirical therapy for hospital-acquired pneumonia (HAP) is stratified according to disease severity – see Severity assessment of HAP.

For patients with low- to moderate-severity HAP, identify the pathogen if possible – see Microbiological investigations for HAP.

If tolerated, oral therapy is recommended for patients with low- to moderate-severity HAP who do not meet the criteria for intravenous therapy below. If oral therapy is not tolerated, consider enteral administration (eg via nasogastric or percutaneous endoscopic gastrostomy [PEG] tube).

Use intravenous therapy for:

• adults with one or more red flags that indicate potential deterioration who do not meet the criteria for high-severity HAP
• children in whom oral therapy is considered inappropriate because of the severity of symptoms and signs – clinical judgement is required
• patients who cannot tolerate oral or enteral therapy.

If a patient continues to deteriorate, consider escalating to broader-spectrum antibiotic therapy – for regimens, see high-severity HAP.

If a patient develops HAP while being treated with antibiotics for another indication, consider escalating to broader-spectrum therapy. For example, if the patient is currently being treated with ceftriaxone for another indication, consider treating HAP as high-severity (eg with piperacillin+tazobactam).

The empirical antibiotic regimens for HAP in these guidelines can be used for initial treatment of aspiration pneumonia in patients who otherwise meet the criteria for HAP. If the patient has had an aspiration event, try to exclude aspiration pneumonitis before starting antibiotic therapy for pneumonia. If aspiration pneumonia is suspected (eg pneumonia in a patient with recurrent aspiration) in a patient who otherwise meets the criteria for low- to moderate-severity HAP, start empirical therapy for low- to moderate-severity HAP.