The following guidelines were prepared by the Alaska Antimicrobial Stewardship Collaborative (A2SC), and are reproduced here as a service to practitioners in the state.
These guidelines have not been reviewed or approved by the Sanford Guide Editorial Board.

Severity and Risk Factor Considerations

Major Criteria

• Septic shock with need for vasopressors
• Respiratory failure requiring mechanical ventilation

Minor Criteria

• Respiratory rate ≥ 30 breaths/min
• Pao2/Fio2 ratio ≤ 250
• Multilobar infiltrates
• Confusion/disorientation
• Uremia (BUN ≥ 20 mg/dl)
• Leukopenia (WBC < 4,000 cells/μl)
• Thrombocytopenia (plts <100,000/μl)
• Hypothermia (<36^o C)
• Hypotension requiring aggressive fluid resuscitation

 **NOTE: Prior categorization of healthcare-associated pneumonia (HCAP) has been abandoned.  The following are NOT predictive of multi-drug resistant pneumonia and should NOT be used alone as an indication for empiric broad-spectrum coverage:

• Hospitalized in an acute care hospital for 2 or more days within 90 days of infection
• Resided in a nursing home or long term care facility
• Received recent chemotherapy or wound care in last 30 days
• Attended a hemodialysis clinic in the last 30 days

Treatment Recommendations

 **NOTE: Dosage recommendations based upon an assumed CrCl > 60 ml/min. If patient has diminished renal function, doses should be dose-reduced.

Non-Severe Infection

Standard Treatment

• Preferred Therapy:
  • Ceftriaxone 1g IV q24hr PLUS
  • Azithromycin 500mg PO/IV q24hr x3 days
• Anaphylactic β-Lactam Allergy:
  • Levofloxacin 750mg PO/IV q24hr

Hospitalized within 90 days PLUS IV antibiotics

• Empiric treatment for MRSA or P. aeruginosa not recommended
• Escalate based upon culture results

Prior MRSA in Respiratory Culture

• Preferred Therapy:
  • Vancomycin 15mg/kg x1 then (Pharmacy to Dose)
  • Ceftriaxone 1g IV q24hr PLUS Azithromycin 500mg PO/IV q24hr x3 days
• Anaphylactic β-Lactam Allergy:
  • Vancomycin 15mg/kg x1 then (Pharmacy to Dose)
  • PLUS Levofloxacin 750mg PO/IV q24hr

 **NOTE: Prior positive cultures within 1 year. If empiric treatment for MRSA or P. aeruginosa, blood and respiratory cultures should be collected prior to antibiotic administration

Prior Pseudomonas in Respiratory Culture

• Preferred Therapy:
  • Cefepime 2gm IV q8hr PLUS Azithromycin 500mg PO/IV q24hr x3 days
• Anaphylactic β-Lactam Allergy:
  • Levofloxacin 750mg PO/IV q24hr PLUS
  • Aztreonam 2gm IV q8hr

 **NOTE: Prior positive cultures within 1 year. If empiric treatment for MRSA or P. aeruginosa, blood and respiratory cultures should be collected prior to antibiotic administration

Severe Infection (1 major or ≥ 3 minor criteria)

Standard Treatment

• Preferred Therapy:
  • Ceftriaxone 1g IV q24hr PLUS
  • Azithromycin 500mg PO/IV q24hr x3 days
• Anaphylactic β-Lactam Allergy:
  • Levofloxacin 750mg PO/IV q24hr +/- Vancomycin 15mg/kg (Pharmacy to Dose)

Hospitalized within 90 days PLUS IV antibiotics

• Empiric MRSA treatment:
  • Add Vancomycin 15mg/kg (Pharmacy to Dose)
• Empiric P. aeruginosa treatment:
  • Substitute Cefepime 2g IV q8h for ceftriaxone

 **NOTE: If empiric treatment for MRSA or P. aeruginosa, blood and respiratory cultures should be collected prior to antibiotic administration

Duration

• 5 days for patients without immunosuppression or structural lung disease
• 7 days for patients with moderate immunosuppression or structural lung disease
• 10-14 days for poor clinical response, initial inappropriate treatment, or significant immunosuppression

 **NOTE: Severe immunosuppression: Neutropenia (WBC < 4 or ANC < 500), HIV+ with CD4 < 200, active chemotherapy, undergone solid organ transplant on active immunosuppression; Moderate immunosuppression: all other diseases (including long-term steroid use with prednisone at 10mg/day or equivalent)

Patients should be afebrile for 48-72hr and demonstrate signs of clinical stability before therapy is discontinued

Aspiration pneumonia

• Addition of anaerobic therapy is NOT recommended unless lung abscess or empyema is suspected.

Suspected or confirmed Influenza

• Oseltamivir 75mg PO BID x5 days
• Certain patient populations are at a higher risk for influenza related complications and may require treatment in absence of confirmed influenza. Refer to local guidelines.

IV to PO

 **NOTE: Total duration IV + PO as above; patient should complete macrolide therapy

• Oral options to consider for de-escalation of β-lactam

  • Preferred Therapy:
    • Amoxicillin 1g PO TID  (If known Strep pneumo and/or cefinase negative H. influenzae / M.catarrhalis use high-dose amoxicillin)
    • Augmentin 875mg BID
      • Consider additional amoxicillin 1g BID in addition to Augmentin for CAP complicated by empyema, asplenia or Strep pneumo PenG MIC 2-4
  • Non-Anaphylactic Penicillin Allergy:
    • Cefuroxime axetil 500mg PO BID

Penicillin Allergy

• If patient reports penicillin allergy, inquire about onset and severity of symptoms, as well as prior beta-lactam exposure and update patient medical record.
• Severe or life-threatening allergic reactions may include: anaphylaxis, angioedema, urticaria, Stevens-Johnson Syndrome (SJS), etc.

Reference

1. Metlay JP, et al. Diagnosis and treatment of adults with community-acquired pneumonia, clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019; 200(7):e45-e67.

Metadata
Approved A2SC Advisory April 2021