We are proud to present CAPSULES Module 9: Hospital Acquired Pneumonia (HAP), now published on ALiEMU. Here is a summary of the key points from a stellar module by Drs. Jamie Rosini and Matt Stanton. When you’re finished, head over to the Capsules page for even more practical pharmacology for the EM provider.
Course Contributors
| Role | Team Member | Background |
| Authors | Jamie M. Rosini, PharmD, MS, BCPS, BCCCP, DABAT @jrozzini | Clinical Pharmacy Specialist, Emergency Medicine; Christiana Care Health System |
| Matthew Stanton, PharmD, BCPS, SPI, DABAT @RxMilwaukee | Emergency Medicine Pharmacist; Froedtert & The Medical College of Wisconsin | |
| Craig Cocchio, PharmD, BCPSÂ @iEMPharmD | Emergency Medicine Pharmacist, Trinity Mother Frances Hospital | |
| PharmD Reviewers | Chris Edwards, PharmD, BCPS @emergencypharm | Emergency Medicine Pharmacist, University of Arizona Medical Center |
| Cole Sloan, PharmD @DrugInfoGeek | Emergency Medicine Pharmacist, University of Utah | |
| Physician Reviewer | Michael Winters, MD FAAEM, FACEP @critcareguys | Associate Professor of Emergency Medicine and Internal Medicine, University of Maryland |
| Copy Editor | Meghan Groth, PharmD, BCPS @EMPharmgirl | Emergency Medicine Pharmacist, UMass Memorial Medical Center |
| Associate Editor | Nadia Awad, PharmD, BCPS @Nadia_EMPharmD |  Emergency Medicine Pharmacist, Robert Wood Johnson University Hospital |
Summary: Hospital-Acquired Pneumonia
In the era of multi-drug resistant bacteria and promotion of quality antimicrobial stewardship, treatment of pneumonia can be a challenging task. This timely CAPSULE discusses the recent update by the Infectious Diseases Society of America (IDSA) guidelines and will assist the reader in risk-factor identification for HAP patients and appropriate antibiotic treatment.
2016 IDSA Guidelines Update
Antibiotic management in patients presenting to the ED with possible pneumonia can be challenging. The new IDSA guidelines for hospital-acquired/ventilator-associated (HAP/VAP) address risk factors for multi-drug resistant (MDR) organisms and methicillin-resistant Staphylococcus aureus (MRSA). The guidelines remove the term ‘healthcare-associated pneumonia.’ Risk stratification can assist with antibiotic decisions. This module focuses on HAP only.
Bugs and Drugs: Identifying Potential Organisms and Optimizing Treatment
Empiric treatment should utilize facility-specific antibiograms and cover the 2 most common pathogens associated with HAP: P. aeruginosa and S. aureus. The use of 2 beta-lactams should be avoided as well as aminoglycoside monotherapy.
| CAPSULE: Antibiotic Selection for Hospital Acquired Pneumonia |
| All patients with suspected HAP should receive an antibiotic that covers Pseudomonas and MSSA, with additional/modified coverage for MRSA or other resistant Gram negative organisms depending on risk factors. |
1 Antibiotic Is Good, But 2 Must Be Better?
P. aeruginosa is associated with a high mortality rate and rapid disease progression. As such, every HAP treatment regimen should include pseudomonal coverage. However, monotherapy is appropriate for patients not considered high risk for death. Theoretical advantages of double coverage for pseudomonal infections include in vitro synergy, avoidance of emerging bacterial resistance on therapy, and enhanced adequacy of the empiric regimen with at least 1 active agent.
| CAPSULE: Risk factors warranting empiric double coverage for Pseudomonas |
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Over-Diagnosing or Under-Treating: To Add or Not Add MRSA Coverage?
MRSA pneumonia can be over-diagnosed if contamination cannot be distinguished from true infection. The Shorr score – an MRSA risk-stratification tool – can be used to determine if MRSA coverage is warranted.1 The increase in antimicrobial resistance underscores how important it is to review past culture data for more resistant Gram-negative pathogen coverage.
| Capsule: Risk factors warranting MRSA coverage |
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| Capsule: Review past culture data |
| Past culture data should be reviewed if available to determine the need for coverage of more resistant Gram-negative pathogens. |
What is the Capsules series?
ALiEMU Capsules is a free, online e-curriculum of high-quality, current, and practical pharmacology knowledge for the EM practitioner. About once a month a new course module is released, which has lessons to read about (or watch) and brief quizzes to complete. With each step, your personal dashboard will keep track of what you have completed. The Capsules series’ primary focus is bringing EM pharmacology education to the bedside. Our expert team distills complex pharmacology principles into easy-to-apply concepts. It’s our version of what-you-need-to-know as an EM practitioner.
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