pneumonia%20-%20hospital-acquired
PNEUMONIA - HOSPITAL-ACQUIRED
Hospital-acquired pneumonia (HAP) is defined as pneumonia occurring ≥48 hours after admission and excluding any infection that is incubating at the time of admission.
Ventilator-associated pneumonia (VAP) is described as pneumonia occurring >48-72 hours after endotracheal intubation and within 48 hours after removal of endotracheal tube.
Early-onset HAP or VAP is the pneumonia occurring within the first 4 days of hospitalization that may be cause by antibiotic-sensitive bacteria that usually carries a better diagnosis.
Late-onset HAP or VAP is the pneumonia occurring after ≥5 days. It is likely caused by multidrug-resistant pathogens associated with increased mortality and morbidity.

Monitoring

Patients w/ Clinical Improvement after 48-72 hours & w/ Negative Cultures
  • May consider discontinuing antibiotics
  • Decision will depend on the clinical course of the patient, type of sample collected & whether or not the reported results are quantitative or semi-quantitative
Patients w/ Clinical Improvement after 48-72 hours & w/ Positive Cultures
  • If possible, de-escalate antibiotics based on culture results
Duration of Therapy
  • Initial empiric therapy should be continued for 7-14 days
    • If a multidrug-resistant (MDR) pathogen is identified, the patient should be treated longer for up to 14 days
  • It has been shown that patients who receive appropriate initial empiric therapy for ventilator-associated pneumonia (VAP) for 8 days have similar outcomes to patients who have received treatment x 15 days
  • If the given combination therapy is an aminoglycoside-containing treatment regimen, aminoglycosides can be stopped after 5-7 days in responding patients
  • If patients are not responding to initial therapy or are rapidly deteriorating, consider broadening antimicrobial coverage while cultures & diagnostic study results are pending
  • These patients should be re-evaluated including careful differential diagnosis & repeat sampling of lower respiratory tract secretions for culture & sensitivities
Patients w/o Clinical Improvement after 48-72 hours & w/ Negative Cultures
  • Evaluate for other organisms or complications
  • Search for other sites of infection
  • Assess for other diagnoses that could be causing the symptoms
Patients w/o Clinical Improvement after 48-72 hours & w/ Positive Cultures
  • Adjust antimicrobial therapy based on culture results
  • Evaluate for other organisms or complications
    • Suspect drug-resistant organisms
  • Search for other sites of infection
  • Assess for other diagnoses that could be causing symptoms

Prevention

  • Encourage healthcare workers & at-risk patients to receive influenza & pneumococcal vaccines

Follow Up

  • Clinical improvement usually becomes apparent w/in the 1st 48-72 hours, wherein antibiotics should not be changed unless progressive deterioration is noted
Follow-up on Day 2 or 3 of Therapy
  • Check cultures/sensitivities
  • Assess patient’s clinical response
    • Assess purulence of sputum
    • Chest x-ray
      • May have limited value in documenting improvement
      • Results lag behind clinical parameters especially in elderly & in those w/ comorbidities
    • Monitor for hemodynamic changes & check organ function
    • Oxygenation (eg PaO2, FiO2)
    • Temperature
    • White blood cells (WBC)
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS Respirology - Malaysia digital copy today!
DOWNLOAD
Editor's Recommendations
Most Read Articles
22 May 2017
Chronic obstructive pulmonary disease (COPD) is currently the 10th commonest cause of death in Singapore, with a disease burden of 5.9 percent according to a 2015 population-based survey (EPIC-Asia survey) in Singapore. Pearl Toh spoke with Dr Augustine Tee, chief and senior consultant of the Department of Respiratory and Critical Care Medicine at Changi General Hospital (CGH) in Singapore, on how COPD is often underdetected in the primary care population as symptoms are not specific and diagnosis requires a combination of clinical risk factors, symptoms and spirometry testing.
15 Aug 2017
New drug applications approved by US FDA as of 1 - 15 August 2017 which includes New Molecular Entities (NMEs) and new biologics. It does not include Tentative Approvals. Supplemental approvals may have occurred since the original approval date.
04 Aug 2017
Chronic obstructive pulmonary disease (COPD) is the fourth cause of global mortality, with experts predicting a potential future rise in the prevalence rates of COPD. 
11 May 2016

In conjunction with World Asthma Day which falls on 3rd May 2016, MIMS Doctor speaks to a renowned respiratory medicine specialist, Dato' Dr. Hj Abdul Razak Abdul Muttalif, regarding the chronic airway disease.