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.

Pneumonia%20-%20hospital-acquired Management

Monitoring

Further Evaluation for Patients Responding to Therapy
Duration of Therapy
  • Initial empiric therapy should be continued for 7 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 7-8 days have similar outcomes (ie mortality rate, disease recurrence, treatment failure, length of hospital stay) to patients who have received treatment x 10-15 days
  • If the given combination therapy is an aminoglycoside-containing treatment regimen, aminoglycosides can be stopped after 5-7 days in responding patients
  • Decision to discontinue antibiotic therapy should be based on clinical evaluation plus biomarkers (eg PCT, CRP, copeptin, MR-proANP)
    • Lessens duration of antibiotic exposure
Patients with Clinical Improvement after 48-72 Hours and with Negative Cultures
  • May consider discontinuing antibiotics
  • Decision will depend on the clinical course of the patient, type of sample collected and whether or not the reported results are quantitative or semi-quantitative
Patients with Clinical Improvement after 48-72 Hours and with Positive Cultures
  • If possible, de-escalate antibiotics based on culture results
Further Evaluation for Patients Not Responding to Therapy
  • If patients are not responding to initial therapy or are rapidly deteriorating, consider broadening antimicrobial coverage while cultures and diagnostic study results are pending
  • These patients should be re-evaluated including careful differential diagnosis and repeat sampling of lower respiratory tract secretions for culture and sensitivities
Patients without Clinical Improvement after 48-72 hours and with 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 without Clinical Improvement after 48-72 hours and with 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

  • Recommended preventive measures by the Society for Healthcare Epidemiology of America and Infectious Diseases Society of America include the following:
    • Avoidance of intubation and use of noninvasive positive pressure ventilation (NIPPV) instead
    • Reducing the use of sedatives, and assessing the patient's readiness for extubation by interruption of sedation and spontaneous awakening trials
    • Physical conditioning and positioning: Early mobilization and head-of-bed elevation to 30°-45°
    • Teeth and mouth hygiene: Mechanical tooth brushing and regular oral care with Chlorhexidine
    • Endotracheal (ET) tube and cuff: Use of ET tubes with secretion drainage ports help reduce pooling of secretions; use of ultrathin polyurethane ET tube cuffs and automated tube cuff pressure control at 20-30 cm H2O may be considered
    • Ventilation circuit maintenance on as-needed basis only
    • Instillation of saline solution before tracheal suctioning
    • Probiotics for immunocompetent patients may help reduce the incidence of VAP and the length of hospital stay in pneumonia patients
  • For patients requiring mechanical ventilation, selective oral decontamination (SOD) with Chlorhexidine or other topical nonabsorbable antibiotics may be considered to eliminate potential pathogens from the oropharyngeal tract
    • Selective digestive decontamination (SDD) by the application of topical nonabsorbable antimicrobial agents to the oropharynx and gastrointestinal tract together with IV antibiotics may also be considered in patients at low risk for antibiotic resistance
  • Encourage healthcare workers and at-risk patients to receive influenza and pneumococcal vaccines

Follow Up

  • Clinical improvement usually becomes apparent within 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 and in those with comorbidities
    • Monitor for hemodynamic changes and check organ function
    • Oxygenation [eg partial pressure of oxygen (PaO2), fraction of inspired oxygen (FiO2)]
    • Temperature
    • White blood cells (WBC)
  • May consider measurement of serum biomarker concentration
    • Includes CRP, procalcitonin (PCT), copeptin and mid-regional pro-atrial natriuretic peptide (MR-proANP)
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