HCAP Replacement

Healthcare Associated Pneumonia is no longer considered a clinically useful category,[1] there is little guidance about how to treat patients with pneumonia who are nonetheless at higher risk for resistant organisms.

Since vancomycin for MRSA and antipseudomonal beta lactams are the central considerations for treating resistant organisms, it may be helpful to simply review when one would consider

Guidance when considering vancomycin for MRSA:

1- If a patient has received broad spectrum IV antibiotics recently (within the last 90 days is a reasonable cutoff).

2- Severe illness, where any potential therapeutic advantage is warranted.

3- The history suggests an acutely worsening viral infection suggestive of bacterial superinfection.  The classic example is staph aureus causing a highly morbid superinfection in the wake of influenza or other respiratory virus.

4- Presence of a cavitary lesion on imaging. Cavitation is a serious infection that suggests necrosis, which suggests staph aureus.


Guidance when considering antipseudomonal beta lactams (pipercillin-tazobactam, cefepime, ceftazidime.)

1- If a patient has received broad spectrum IV antibiotics recently (within the last 90 days is a reasonable cutoff).

2- Severe illness, where any potential therapeutic advantage is warranted.

3- If a patient has structural lung disease (bronchiectasis, prior cavitary lesion, cystif fibrosis, etc.)


Important caveats:
1- A negative nasal MRSA swab essentially rules out MRSA pneumonia.[2]

2- Sputum culture is low yield, but harmless and potentially very helpful, especially patients with structural lung disease who often have prior respiratory cultures for guidance.






[1] Mortality in patients with HCAP appears more likely due to comorbid conditions in these chronically ill patients than due to resistant organisms. 
Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis. 
Clin Infect Dis. 2014 Feb;58(3):330-9. doi: 10.1093/cid/cit734. Epub 2013 Nov 22.
https://www.ncbi.nlm.nih.gov/pubmed/24270053

[2] Predictive Value of Methicillin-Resistant Staphylococcus aureus (MRSA) Nasal Swab PCR Assay for MRSA Pneumonia
Antimicrob Agents Chemother. 2014 Feb; 58(2): 859–864.