De-escalation of therapy and intravenous to oral switch for VAP

If there is no strong evidence to support the diagnosis of ventilator-associated pneumonia (VAP), stop antibiotic therapy.

Once the patient has improved and is clinically stable, switch to oral (or enteral) therapy, even if a pathogen is not identified. For guidance on when to switch to oral therapy, see Guidance for intravenous to oral switch. The choice of oral therapy for VAP depends on the results of microbiological investigations.

If the pathogen is known, see Directed therapy for pneumonia.

If a pathogen is not identified in adults and children with VAP, and it is appropriate to switch to oral therapy, use:

amoxicillin+clavulanate 875+125 mg (child 2 months or older: 22.5+3.2 mg/kg up to 875+125 mg) orally or enterally, 12-hourly¹. See advice on Duration of therapy for VAP. For dosage adjustment in adults with kidney impairment, see amoxicillin+clavulanate oral dosage adjustment. amoxicillin + clavulanate amoxicillin+clavulanate amoxicillin+clavulanate

For adults and children with nonsevere (immediate or delayed) penicillin hypersensitivity, or severe immediate² penicillin hypersensitivity who tolerated ceftriaxone, cefotaxime or cefepime³, use:

cefuroxime 500 mg (child 3 months or older: 15 mg/kg up to 500 mg) orally or enterally, 12-hourly⁴. See advice on Duration of therapy for VAP. For dosage adjustment in adults with kidney impairment, see cefuroxime dosage adjustment. cefuroxime cefuroxime cefuroxime

For adults with severe immediate² penicillin hypersensitivity in whom ceftriaxone, cefotaxime or cefepime was not used nor tolerated, or for patients with severe delayed⁵ penicillin hypersensitivity, use:

1moxifloxacin 400 mg orally or enterally, daily⁶. See advice on Duration of therapy for VAP. For dosage adjustment in adults with kidney impairment, see moxifloxacin dosage adjustment moxifloxacin moxifloxacin moxifloxacin

1trimethoprim+sulfamethoxazole 160+800 mg orally or enterally, 12-hourly. See advice on Duration of therapy for VAP. For dosage adjustment in adults with kidney impairment, see trimethoprim+sulfamethoxazole dosage adjustment. trimethoprim + sulfamethoxazole trimethoprim+sulfamethoxazole trimethoprim+sulfamethoxazole

For children in whom a suitable formulation of cefuroxime is not available, trimethoprim+sulfamethoxazole or moxifloxacin may be suitable alternatives. These can also be used for children with severe immediate² penicillin hypersensitivity in whom ceftriaxone, cefotaxime or cefepime was not used nor tolerated, or for patients with severe delayed⁵ penicillin hypersensitivity. Trimethoprim+sulfamethoxazole is preferred because there are fewer data for moxifloxacin in children. Use:

1trimethoprim+sulfamethoxazole (child 1 month or older) 4+20 mg/kg up to 160+800 mg orally or enterally, 12-hourly. See advice on Duration of therapy for VAP trimethoprim + sulfamethoxazole

2moxifloxacin 10 mg/kg up to 400 mg orally or enterally, daily⁷ ⁸. See advice on Duration of therapy for VAP. moxifloxacin

¹ Amoxicillin+clavulanate may be suitable for children aged 1 month to younger than 2 months but a different dosage is required.Return

² Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

³ For patients with severe immediate penicillin hypersensitivity who tolerated initial intravenous therapy with ceftriaxone, cefotaxime or cefepime, it is safe to use cefuroxime.Return

⁴ Cefuroxime is preferred to cefalexin or cefaclor because of its superior antipneumococcal activity; see Practical information on using beta lactams: cephalosporins for further information.Return

⁵ Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return

⁶ An oral liquid formulation of moxifloxacin is not commercially available; for formulation options for adults with swallowing difficulties, see Don’t Rush to Crush, which is available for purchase from the Advanced Pharmacy Australia website or through a subscription to eMIMSplus.Return

⁷ Moxifloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, clinical trial data suggest that adverse musculoskeletal events are usually mild and short term, similar to those observed in adults. Moxifloxacin can be used in children when it is the drug of choice.Return

⁸ An oral liquid formulation of moxifloxacin is not commercially available; for formulation options for children, see Don’t Rush to Crush, which is available for purchase from the Advanced Pharmacy Australia website or through a subscription to eMIMSplus.Return