Safety considerations of current drug treatment strategies for nosocomial pneumonia

ABSTRACT

Introduction: Nosocomial pneumonia unfortunately remains a frequent event for which appropriate antibiotic treatment is central to improving outcomes. Physicians must choose an early and appropriate empirical treatment, basing their decision on the safety profile and possible side effects.

Areas covered: In this review, we analyzed the safety profiles of the most common antimicrobials for treating nosocomial pneumonia. Beta-lactams are used most often for these infections, with a high percentage (6% to 25%) of patients reporting allergy or hypersensitivity reactions; however, exhaustive evaluation is key because it seems possible to de-label as many as 90% by proper assessment. Combinations including a beta-lactam are recommended in patients with risk factors for drug-resistant microorganisms and septic shock. Although aminoglycosides are safe for 3–5 days of therapy, renal function should be monitored. Fluoroquinolones must also be used with care given the risk of collagen degradation and cardiovascular events, mainly aneurysm or aortic dissection. Linezolid or vancomycin are both viable for the treatment of methicillin-resistant Staphylococcus aureus, but linezolid seems to be the superior option. Antibiotic stewardships programs must be developed for each center.

Expert opinion: Choosing the most appropriate antimicrobial based on information from national and international guidelines, local microbiology data, and stewardship programs may reduce the use of broad-spectrum antibiotics. Daily assessment for the emergence of adverse events related to antimicrobial use is essential.

KEYWORDS:

• Nosocomial pneumonia
• antibiotics
• treatment
• safety

Article highlights

• Early and appropriate antibiotic treatment is a cornerstone in the treatment of pneumonia.

• Dosing guided by therapeutic drug monitoring or extended continuous intravenous infusion have shown improved outcomes.

• Using risk stratification, skin testing, and amoxicillin challenges will adequately exclude beta-lactam allergy.

• Combinations of vancomycin and piperacillin–tazobactam must be avoided when other combined treatments are available because they may increase the incidence of kidney injury.

• Negative MRSA nasal swab may allow rapid de-escalation of anti-MRSA antimicrobial treatments.

• In the absence of alternative options, colistin and tigecycline may be indicated for patients with MDR microorganisms but their unfavorable safety profile must be borne in mind.

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

A reviewer on this manuscript has disclosed that they have received grant funding (Merck, Medical Titan Group). All other peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This study was supported by CIBERES and IDIBAPS.