Current Guidelines in

HAP and VAP Management

Ahmad Rasyid, dr, SpPD, K-P

dr.ahmadrasyid@yahoo.co.id

Div.of Pulmonology, Dept.of Internal Medicine

Faculty of Medicine, University of Sriwijaya /
Mohammad Hoesin General Hospital, Palembang

1
 Pneumonias – Classification

Nosocomial
Pneumonias

ATS/IDSA. Am J Respir Crit Care Med. 2005;171:388-416.

2
Pan-European guideline on HAP. J Antimicro Chemo 2007
 Nosocomial Pneumonias (HCAP,HAP,VAP)
Pneumonia yang terjadi di rumah sakit:
- Pneumonia Nosokomial di RS (PN),
- ventilator associated pneumonia-VAP
- healthcare-associated pneumonia-HCAP (2005).

Faktor risiko :
1. Faktor yang tidak bisa dirubah yaitu berkaitan dengan
inang (seks pria, penyakit paru kronik, atau gagal organ
jamak),
2. Faktor tindakan invasif (intubasi atau slang nasaogastrik).
→ Upaya:mengontrol infeksi, disinfeksi dengan alkohol,
pengawasan patogen resisten (multidrug resistent -MDR),
penghentian dini pemakaian alat yang invasif

Faktor risiko kritis ventilasi mekanik > 48 jam, lama rawat di

ICU, skor APACHE, ARDS (acute respiratory distress syndrome)
3
 Definitions
1. Hospital-acquired 3. Health care-associated
pneumonia (HAP)
• Pneumonia occurring
pneumonia (HCAP)
 48 hours post-hospital Includes HAP and VAP
admission Pneumonia in patients
• Hospitalized for  2 days in an
acute care facility within 90 days
2. Ventilator-associated of infection
pneumonia (VAP) • Residing in a nursing home or
• Pneumonia occurring long-term care (LTC) facility
 48-72 hours post-intubation • Attending a hospital or
. Early onset (<4 days),→ better hemodialysis clinic
prognostic, AB sensitive • Receiving immunosuppressive
. Late onset (>5 days),→ therapy or wound care within 30
- MDR pathogen days of infection
-↑morbidity & mortality

4
ATS/IDSA. Am J Respir Crit Care Med. 2005;171:388-416.
 Epidemiology of HAP
HAP is the 2nd most common hospital-acquired infections
after UTI.
Incidence 5-15 / 1000 hospital admissions.
Accounting for 31 % of all nosocomial infections.
HAP is the leading cause of death from hospital-acquired
infections.
The incidence of HAP is highest in ICU (25%).
The incidence of HAP in ventilated patients was 5-20 fold
higher than non-ventilated patients.

Med Clin of North Am. 2001;85:1583-94

ATS/IDSA guidelines. AJRCCM 2005;171:388-415

5
 HAP, VAP, and HCAP Mortality

1. Crude mortality rate for HAP may be as high as 30% - 70%

• However, many critically ill patients with HAP do not die of
pneumonia, but rather of their underlying disease

2. Mortality attributable to HAP estimated at 33% to 50%

3. Increased mortality rates were associated with

• Bacteremia
• P aeruginosa or Acinetobacter spp
• Medical, not surgical illness
• Ineffective antibiotic therapy

ATS/IDSA. Am J Respir Crit Care Med.

2005;171:388-416.
Heyland DK et al. Am J Respir Crit Care Med.
6
1999;159:1249-1256.
 Faktor Risiko Utama Untuk Patogen Tertentu
Pada Pneumonia Nosokomial

Patogen Faktor Risiko

- Staphylococcus aureus
- Methicillin resisten S. aureus
- Ps. aeruginosa
- Anaerob
- Acinobachter spp.
- Koma, cedera kepala,influenza, pemakaian
obat IV, DM, gagal ginjal
- Pernah dapat antibiotik, ventilator > 2 hari
- Lama dirawat di ICU, terapi steroid/ antibiotik,
- Kelainaan struktur paru (bronkiektasis,kistik
Fibrosis), malnutrisi
- Aspirasi, selesai operasi abdomen
- Antibiotik sebelum onset pneumonia dan
ventilasi mekanik

7
 ETIOLOGY

HAP, VAP, and HCAP

1. Aerobic gram-negative bacilli (eg, Escherichia coli,
Klebsiella pneumoniae, Enterobacter spp,
Pseudomonas aeruginosa, Acinetobacter spp)
2. Gram-positive cocci (eg, Streptococcus spp,
Staphylococcus aureus, including methicillin-resistant
S. aureus (MRSA).
3. Viruses or fungi is significantly less common except in
the immuno-compromised patient.

8
Diagnosis of Hospital Acq. Pneumonia
It is still a major problem for clinicians, because
HAP diagnosis is often difficult to make.

The objective is to determine :

1. Whether the patient has pneumonia.
2. The etiologic pathogen.
3. The severity of illness.
Approaches to diagnosis :
Clinical : - history: cough, chest pain, purulent sputum
- physical examination : fever, lung abnormality.
- limited lab. : chest X-ray, blood culture.
Invasive / quantitative : • fiber-optic bronchoscopy/
needle aspiration.
• quantitative culture results.

9
Diagnosis of Pneumonia

• Imaging
• Gram's stain and culture
• Bronchoscopy

10
 Imaging
• Limited value in ventilated patients.
• In one study, only 1/3 of ventilated patients with a
new or worsening alveolar infiltrate had
pneumonia at autopsy
• No single radiological sign was clearly correlated
with the diagnosis.
• The most reliable sign was the finding of air
bronchograms, but predicted pneumonia in only
64% of cases.
• ARDS and alveolar hemorrhage were the most
common disorders mistaken for pneumonia.
11
 Gram's stain and culture
• Unreliable due to contamination with bacteria colonizing
the oro-pharynx.

• The presence of many PMN leukocytes (and few epithelial

cells) and bacteria, which are morphologically consistent
with bacteria found on culture, improve the predictive
power.

• In addition, the lack of isolation of a pathogen (e.g, MRSA

or Pseudomonas) from a well-collected and adequate
expectorated sputum sample can be used to narrow the
antimicrobial regimen.

• Blood cultures are extremely helpful when positive, but the

yield is low.
12
 Bronchoscopy
Protected brush specimen (PBS)
• Using a threshold of >1.000 colony forming units
(CFU)/mL
• sensitivity : 64 - 100 %
• specificity : 60 - 100 %
Bronchoalveolar lavage (BAL)
• Samples approximately 1.000.000 alveoli, recovers 5-
10 x the number of organisms obtained by PBS.
Quantitative cultures using a threshold of >10.000
CFU/mL
• sensitivity : 72 - 100 %
• specificity : 69 - 100 %
Quantification of intracellular organisms in BAL
specimens is a rapid and specific test and can be used
as a guide to initial therapy 13
CRITERIA OF HAP SHOULD BE CONSIDERED

1. Purulent tracheal secretions, and new

and/or persistent infiltrate on CXR
2. Increased oxygen requirement
3. Coe temperature > 38,3°C
4. Blood leucocytosis (>10.000/mm³) or
leucopenia (<4000/mm³)

15
 Risk Factors for Multidrugs-Resistant (MDR)
Pathogens Causing HAP, VAP & HCAP
• Antimicrobial therapy in preceding 90 days

• Current hospitalization of  5 days

• High frequency of community or hospital-unit antibiotic

resistance

• Presence of risk factors for HCAP :

– Hospitalization for  2 days in preceding 90 days
– Residence in a nursing home or LTC facility
– Home infusion therapy (including antibiotics)
– Chronic dialysis within 30 days
– Home wound care
– Family member with Multi Drugs Resistant Pathogen

• Immunosuppressive disease and / or therapy 17

ATS/IDSA. Am J Respir Crit Care Med. 2005;171:388-416.
Principles underlie the management
of HAP, VAP, and HCAP
1. Avoid the overuse of antibiotics by focusing
on accurate diagnosis, tailoring therapy to
the results of lower respiratory tract
cultures, and shortening duration of therapy
to the minimal effective period.

2. Apply prevention strategies aimed at

modifiable risk factors

19
Principles underlie the management
of HAP, VAP, and HCAP
3. Avoid untreated or inadequately treated HAP,
VAP, or HCAP, because the failure to initiate
prompt appropriate and adequate therapy has
been a consistent factor associated with
increased mortality.

4. Recognize the variability of bacteriology from

one hospital to another, specific sites within the
hospital, and from one time period to another,
and use this information to alter the selection of
an appropriate antibiotic treatment regimen for
any specific clinical setting.
20
 The Microbiology of HAP

Early-onset Late-onset
pneumonia pneumonia Others based on
( < 5 days) (  5 days) specific risks

S. pneumoniae P. aeruginosa Anaerobic bacteria

H. influenzae Enterobacter spp. Legionella pneumophila
S. aureus Acinetobacter spp.
Enterobacteriaceae K. pneumoniae
S. marcescens Influenza A and B
E. coli Respiratory syncytial
Other Gr Neg Bacl virus
S. aureus (MRSA) Fungi

GNB, Gram-negative bacilli; MRSA, methicillin-resistant S.aureus

21
Adapted from Am J Respir Crit Care Med. 2005;171:388–416.
 Importance of appropriate
empiric therapy
• Antibiotic therapy is ‘inappropriate’ when it is
• ineffective in vitro against the infecting organism or
• not given promptly by a suitable route

• Inappropriate treatment is associated with increased

mortality in patients with life-threatening infections.

• Initial short courses of broad-spectrum antibiotics

followed by more targeted therapy once the infecting
organism has been identified may improve patient
outcomes.

22
French GL. Advanced Drug Delivery Reviews 2005; 1514-1527.
 Benefits of Early, Appropriate Therapy

Cumulative evidence from multiple studies has demonstrated

that early, appropriate therapy is associated with:

1. Shorter duration of antibiotic therapy.

• Short-course therapy is only an option when the right
antibiotic is used from the start
2. Decreased length of ICU or hospital stay
3. Lower total cost
4. Decreased mortality.
• Appropriate antimicrobial therapy reduces infection-
related and all-cause mortality
Craven DE et al. Infect Dis Clin North Am. 2004;18:939-962.
23
Singh N et al. Am J Respir Crit Care Med. 2000;162:505-511.
Lodise TP et al. Cin Infect Dis. 2003;36:1418-1423.
 Improving Outcomes

• Prevention
• Decreasing resistance
• Improving our antibiotic
selections

24
 De-escalation Approach to
Antimicrobial Utilization
Bacterial infection suspected (HAP, VAP, Sepsis)

Obtain microbiologic stains/cultures and begin appropriate

empirical antimicrobial therapy based on patient risk factors
for MDR pathogens and local susceptibility patterns

Evaluate for clinical response at 48 to 72 hours based on

temperature, WBC, radiographs, oxygenation, hemo-dynamic
changes and organ function

Clinical improvement No clinical improvement

Reassess patients for the following:

Narrow antimicrobial spectrum based on
microbiologic data and reassess need for
continued therapy after 7 to 8 days
1. Pathogen resistant to prescribed therapy
2. Complication present (abscess, empyema)
3. Noninfectious diagnosis (drug fever)
25
Kollef et al. CID 2008; 47: S3-S9
Empiric Antibiotic Therapy for HAP
HAP or VAP
(All Disease Severity)

Late Onset ( 5 days) or Risk Factors for Multi-drug

Resistant (MDR) Pathogens

No Yes
Limited Spectrum Antibiotic Broad Spectrum Antibiotic
Therapy Therapy For MDR Pathogens

(Algorithm for initiating empiric antibiotic therapy for HAP or VAP) 26

 Recommendations
Initial EMPIRIC therapy for HAP or VAP in patients with no known risk factors for
MDR pathogens, early onset, and any disease severity

Potential Pathogen Recommended Antibiotic

S. pneumoniae1 Ceftriaxone
H. influenzae
Methiciin Sensitif Staphy. Aureus or
Antibiotic-sensitive enteric Gram (-)
bacilli Levofloxacin, moxifloxacin, or
E. coli ciprofloxacin
K. pneumoniae
Enterobacter species or
Proteus species
Serratia Marcescens Ampicillin/sulbactam

or

Ertapenem

1. The frequency of PRSP and MDRSP in increasing; levofloxacin or moxifloxacin are preferred27 to
ciprofloxacin and the role of other new Quinolones, such as gatifloxacin, has not been established
 Recommendations
Initial EMPIRIC therapy for HAP, CAP, and HCAP in patients with late-onset disease or risk
factor for MDR pathogens and all disease severity

Potential Pathogen Recommended Antibiotic

Pathogens listed in previous table and Antipseudomonal cephalosporin
MDR pathogens (cefipime, ceftazidime)
P. aeruginosa or
K. pneumoniae (ESBL+)1 Antipseudomonal carbepenem
Acinetobacter species1 (imipenem or meropenem)
or
-Lactam/-lactamase inhibitor
(piperacillin-tazobactam)
plus
Antipseudomonal Fluroquinolone1
(levofloxacin or ciprofloxacin)2
or
Aminoglycoside
(amikacin, gentamicin, or tobramycin)
MRSA
plus
Legionella pneumophila1
Linezolid or vancomycin3
1. If an ESBL+ strain, such as K. pneumoniae, or an Acinetobacter species is suspected, a carbepenem is a reliable choice. If L. pneumophila
is suspected, the combination antibiotic regimen should include a macrolide (e.g. azithromycin) or a fluoroquinolone (e.g. levofloxacin or
ciprofloxacin) should be used rather than an aminoglycoside
2. Levofloxacin 750mg q12h, ciprofloxacin 400mg q8h 28
3. If MRSA risk factors are present or there is a high incidence locally
Dosis Intravena Awal Antibiotika Untuk Empirik Terapi Pada Pneumonia
Nosokomial, Pneumonia Yang Berhubungan Dengan Ventilator, dan Pneumonia
Pada Perawatan Kesehatan Pada Pasien Onset Lanjut Atau Dengan Faktor Risiko
Patogen Resisten Antibiotika Jamak.

Antibiotika Dosis IV Awal Antibiotika Yang disarankan

Antipseudomonas sefaloseforin
- cefepime 1-2 gram tiap 8- 12 jam
- ceftazidime 2 gram tiap 8 jam
Carbapenem :
- Imipenem 0,5 gram tiap 6 jam atau 1 gram tiap 12 jam
- Meropenem 1 gram tiap 8 jam
B laktam / B laktamase inhibitor :
- Piperacillin- tazobactam 4,5 gram tiap 6 jam
Aminoglikosida :
- Gentamycin 7 mg/kg/ hari
- Toramycin 7 mg/kg/ hari
- Amikasin 20 mg/kg/ hari
Antipseudomonas quinolone (IV/ PO)
- Levofloxacin 750 mg/ hari
- Gatifloxacin 400 mg/ hari
- Ciprofloxacin 400 g/ 8 jam
Vancomycin for MRSA 15 mg/ kg/ 8-12 jam
Linezolid for MRSA 600 mg/ 12 jam

Dosis berdasarkan fungsi ginjal dan hati yang normal. 31

 Terapi Suportif
1. Terapi O2 untuk mencapai PaO2 80-100 mmHg
2. Humidifikasi dengan nebulizer
3. Fisioterapi dada
4. Pengaturan cairan.
5. Pemberian kortikosteroid pada fase sepsis berat
6. Obat inotropik : dobutamin atau dopamin terdapat
komplikasi gangguan sirkulasi atau gagal ginjal
prerenal.
7. Ventilasi mekanis : PEEP menurunkan FiO2
menjadi 50% atau lebih rendah
8. Drainase empiema bila ada.
9. Nutrisi dengan kalori yang cukup, dihindari
produksi CO2 yang berlebihan.

32
 British Society for Antimicrobial Therapy
(publication 9 April 2008)

- Initial appropriate AB therapy, as soon as VAP is suspected

- Empirical AB for HAP be based on the empirical in unit,
recent AB therapy and comorbiditas
- Early onset infection (<5 days of admission) :
- not previosly received AB, absence other risk factors :
co-amoxiclav or cefuroxime
- recently received AB and have other risk factors :
third generation cephalosporin (cefotaxime or ceftriaxone)
fluoroquiolone or piperacillin/tazobactam
- If patients respond to therapy, duration empiric not > 8 days

33
- Th/ wih appropriate AB should started as soon as possible
- Treatment options HAP cause by P. Aeruginosa : Ceftazidime,
Ciprofloxacine, Meropenem, Piperacilline/tazobactam
- No firm conclusion the use linezolid or glycopeptide as
optimal treatment of HAP/VAP
- The decisions the conversin of IV to oral in HAP must be take
on case by case according to therapuetic clinical respons
- Patient HAP with sepsis, organ failure : Should be considered
treatment activated protein C, not with G-CSF
- Routine use steroid of case HAP cannot be promoted
(evidence is very limited)

34
 Conclusions
1. HAP are increasing health problems nowadays, associated
with high morbidity, mortality rates, cost and length of
hospital stay.

2. Diagnosis of HAP can be done clinically. Initial empirical

therapy needs to be executed promptly.

3. Empirical antibiotic is based on reliable

recommendation/guideline and local sensitivity data.

4. Pay attention to the management of Multi Drugs Resistant

Pathogens.

5. Taking specimen for Microbial Identification before

antibiotics administration is a must. 35
Thank you

36
 Kriteria Diagnosis Nosocomial Pneumonia
Harus Memenuhi Satu dari 4 Kriteria :

1. Ronki atau dullness pada perkusi torak, Ditambah salah satu:

a. Onset baru sputum purulen atau perubahan karakteristiknya
b. Isolasi kuman dari darah
c. Isolasi kuman dari bahan yang didapat dari aspirasi transtrakeal, biopsi atau
sapuan bronkus

2. Gambaran radiologis berupa infiltrat baru yang progresif, konsolidasi, kavitasi, /

efusi pleura. Dan salah satu dari a, b, atau c di atas
d. Isolasi virus atau deteksi antigen virus dari sekret respirasi.
e. Titer antibodi tunggal yang diagnostik (lgM), atau peningkatan 4x titer lgG dari
kuman
f. Bukti histopatologis pneumonia

3. Pasien sama atau < 12 tahun dengan 2 dari gejala - gejala berikut: apnea,
takipnea, bradikardia, wheezing, ronki, atau batuk, disertai salah satu dari:
g. Peningkatan produksi sekresi respirasi / salah satu dari kriteria no.2 di atas.

4. Pasien sama atau <12 tahun yang menunjukkan infiltrat baru / progresif, kavitasi,
konsolidasi atau efusi pleura pada foto torak. Ditambah salah satu dari kriteria 38
No.3 di atas.
 Importance of Initial, Appropriate
Antibiotic Therapy
“…selection of initial appropriate antibiotic therapy (ie, getting the antibiotic treatment right the
first time) is an important aspect of care for hospitalized patients with serious infections.”
– ATS/IDSA Guidelines

A Study by Kollef and Colleagues Evaluating the Impact of Inadequate Antimicrobial Therapy on Mortality
60

52* *P<.001
50
42*
Hospital Mortality (%)

40

30
24
18
20

10

0
All-Cause Mortality Infection-Related Mortality

Inadequate antimicrobial treatment (n=169)

Adequate antimicrobial treatment (n=486)
Adapted from Kollef MH et al. Chest. 1999;115:462-474.
39
ATS/IDSA. Am J Respir Crit Care Med. 2005;171:388-416.
Rekomendasi Dalam Pengelolaan Faktor Risiko Yang dapat dirubah.

Faktor Inang
- Nutrisi adekuat, makanan enteral dengan slang nasaogastrik
- Reduksi/ penghentian terapi imunosupresif
- Cegah ekstubasi yang tidak direncanakan (tangan diikat, beri sedasi)
- Tempat tidur yang kinetik
- Spirometer insentif, nafas dalam, kontrol rasa nyeri
- Mengobati penyakit dasar
- Menghindari penghambat histamin tipe 2 dan antasida
Faktor Alat
- Kurangi obat sedatif dan paralitik
- Hindari overdistensi lanbung
- Hindari intubasi dan reintubasi
- Pencabutan slang endotrakheal dan nasogastrik yang terencana
- Posisi ½ duduk (30- 40 derajat)
- Jaga saluran ventilator bebas dari kondensasi
- Tekanan ujung slang endotrakheal > 20 cmH2O (menjaga kebocoran patogen
ke saluran nafas bawah)
- Aspirasi sekresi epiglottis yang kontinyu
Faktor Lingkungan
- Pendidikan
- Menjaga prosedur pengontrol infeksi oleh staf
- Program pengontrolan infeksi
40
- Mencuci tangan, desinfektasi peralatan
 Pencegahan
Terkait erat dengan pemberian terapi yang
tidak tepat, tidak adekuat atau terlambat
akan mengakibatkan kesulitan terapi atau
pencegahan yang sebelumnya meringankan
masalah terapi

41
 Pneumonia Komunitas
vaksinasi influenza dan pneumokokus orang dengan risiko
tinggi, gangguan imunologis, penyakit berat
Penghuni rumah jompo atau rumah penampungan panyakit
kronik, dan usia di atas 65 tahun.

Pneumonia Nosokomial
program pengawasan dan pengontrolan infeksi mengurangi
terjadinya Nosocomial Pneumonia
pembatasan pemakaian selang nasogastrik atau
endotrakeal atau dengan cara pemakaian obat sitoprotektif
sebagai pengganti antagonis H2 dan antasid.
42
 CHARACTERISTIC SEVERE COMMUNITY ACQUIRED
PNEUMONIA ADMITTED TO ICU
Kelompok/
P F R
Ruang
K P P
PATOGEN
Rawat
P A Str M V C Inf L S H Gr An M H My
pn p Re pn G eg au Inf (-) ae cat Inf tb
n s

IV.Rawat
ICU : a + + - + + - +/- +/ + + + + - - +
b + + + + + - +/- + + + + - - +

Terapi
IV antipseudomonas laktam; ditambah: iv ciprofloxacin ; atau
IV laktam ditambah aminoglikosida ditambah salah satu IV azitrhromycin atau
ciprofloxacin
Keterangan :
PKP : penyakit kardiopulmonal. FP : faktor perubahan. RPA: risiko Ps.Aeruginosa
Str.pn: Str. Pneumoniae. M.pn: M Pneumoniae. Ch.pn : C. Pneumoniae. Nf.G: catarrhalls.
Leg: Legionella. Mtb: M.tuberculosis
Pada PK berat dgn pasca influenza, DM, gagal ginjal
43
Faktor- faktor yang dipertimbangkan pada
pemilihan Antibiotika pada pasien CAP
a. Faktor pasien. urgensi/ cara pemberian obat berdasarkan tingkat berat
sakit ISNBA dan keadaan urnum/ kesadaran, mekanisme imunologis, urnur,
defisiensi genetik/ organ, kehamilan, alergi.

b. Faktor antibiotik : dipahami berbagai aspek tentang AB untuk efisiensi

pemakaian AB, dipilih AB yg merupakan obat pilihan utama berdasarkan
data antibiogram mikrobiologi dalam 6-12 bulan terakhir.

c. Faktor farmakologik. Utk efektivitas optimal, dipilih obat :

- dose dependent (misalnya sefalosporin) diberikan dalam 3-4 x pemberian/ hr
- concentration dependent (misalnya aminoglikosida, kuinolon) cukup 1-2
kali sehari namun dengan dosis yang lebih besar.

Farmakodinamik : kemampuan AB untuk melakukan penetrasi ke lokasi infeksi

dan keampuhannya AB hingga obat ini ampuh . Obat dengan kadar intraseluler
lebih efektif dalam membunuh kuman intraseluler.

AB dengan Cmax /MIC Ratio >8- 10, atau AUC: MIC Ratio yang semakin >25
semakin efektif dan bila AUC/MIC Ratio >100, menekan terjadinya
perkembangan resistensi patogen.
44
 Stratifikasi Untuk terapi
P F R
Kelomp K P P

ok/
P A Patogen Terapi
Ruang
S M V C I L S H G A M H M
Rawat tr p R p n e a i r n c i y
p n e n f g u n (- a a n t
n s G f ) e t f b

I.Rawat - - - + + + + + - - + - - + + + Makrolid baru atau

/- /- /- /- /-
Jalan 1 doxycycline
)

II. + + + + + + + + + + + + + + + + Laktam (cefuroxime,

/- /- / /- /- 3 2 /- /- /- /- axoxyclavulanat; atau
Rawat P ) ) ceftriaxone iv diteruskan
Jalan R
cefodoxime po);
S
P ditambah makrolid baru.
Atau Fluoroquinolone
saja (levofloxacin)

IIIa. + + - + + - + + + + + + + + + + Laktam IV (cefotaxime,

/- /- 3 /- ceftriaxone);
Rawat ) 2 Ditambah IV/ po makrolid;
Inap RS )
atau fluoroquinolone saja
(levofloxacin)

IIIb. - - - + + - + + + + - - - + + IV azytrhromycin atau

/- 3 /- doxycycline dan laktam.
Rawat ) Atau fluoroquinolone saja
Inap RS (levofloxacin)

IV. + + - + + - + + + + + + - - + IV antipseudomonas laktam

+ + + + + - /- / + 3 + + - - + (piperacillin/ tazobactam);
Rawat + + ) ditambah: iv ciprofloxacin ;
a. /- /-
Atau IV antipseudomonas
ICU: laktam ditambah
aminoglikosida ditambah
b. 45
salahsatu IV azitrhromycin
b. atau ciprofloxacin