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 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
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 & 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 without 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 without 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

  • Recommended preventive measures by the Society for Healthcare Epidemiology of America & Infectious Diseases Society of America include the following:
    • Avoidance of intubation & use of noninvasive positive pressure ventilation (NIPPV) instead
    • Reducing the use of sedatives, & assessing the patient's readiness for extubation by interruption of sedation & spontaneous awakening trials
    • Physical conditioning & positioning: Early mobilization & head-of-bed elevation to 30°-45°
    • Teeth & mouth hygiene: Mechanical tooth brushing & regular oral care w/ Chlorhexidine
    • Endotracheal (ET) tube & cuff: Use of ET tubes w/ secretion drainage ports help reduce pooling of secretions; use of ultrathin polyurethane ET tube cuffs & 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 & the length of hospital stay in pneumonia patients
  • For patients requiring mechanical ventilation, selective oral decontamination (SOD) w/ 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 & gastrointestinal tract together w/ IV antibiotics may also be considered in patients at low risk for antibiotic resistance
  • Encourage healthcare workers & at-risk patients to receive influenza & 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 & in those w/ comorbidities
    • Monitor for hemodynamic changes & 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 & mid-regional pro-atrial natriuretic peptide (MR-proANP)
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