Approach to managing high-severity HAP
Empirical therapy for hospital-acquired pneumonia (HAP) is stratified according to disease severity – see Severity assessment of HAP.
For patients with high-severity HAP, identify the pathogen if possible – see Microbiological investigations for HAP. For patients with immune compromise, consider performing investigations for a broader range of pathogens (see Aetiology of HAP in patients with immune compromise), and seek expert advice on whether to adjust empirical antibiotic therapy while awaiting the results.
For patients with high-severity HAP who have sepsis or septic shock, start antibiotic therapy within 1 hour of development of sepsis or septic shock, immediately after blood samples are taken for culture. Collect sputum samples (or for intubated patients, lower respiratory tract samples) as soon as possible; however, do not delay antibiotic administration to do so. For nonantibiotic management of sepsis or septic shock, see Resuscitation of patients with sepsis or septic shock.
The empirical therapy regimens for high-severity HAP are active against a broad range of pathogens, including Pseudomonas aeruginosa. Consider the need for additional therapy in patients with:
Initial therapy for atypical pathogens1 (eg Legionella) is not routinely required for patients with HAP.
If a patient develops high-severity HAP while being treated with broad-spectrum antibiotics (eg piperacillin+tazobactam), seek expert advice.
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 high-severity HAP, start empirical therapy for high-severity HAP.