Hospital pneumonia

1. By- Dr. Armaan SinghBy- Dr. Armaan Singh

2.  Community acquired pneumonia (CAP)
 Infection of the lung parenchyma in a person who is not hospitalized or living in
a long-term care facility for ≥ 2 weeks
 Hospital-acquired pneumonia (HAP)
 Occurs 48 hours or more after admission, which was not incubating at the time of
admission
 Healthcare-associated pneumonia (HCAP) is
defined as pneumonia that occurs in a non-
hospitalized patient with extensive healthcare
contact, as defined by one or more of the
following:
 Intravenous therapy, wound care, or intravenous chemotherapy within the prior
30 days.
 Residence in a nursing home or other long-term care facility
 Hospitalization in an acute care hospital for two or more days within the prior 90
days
 Attendance at a hemodialysis clinic within the prior 30 days
 Ventilator-associated pneumonia (VAP)
 Arises more than 48-72 hours after endotracheal intubation

3. • Common clinical features
– Cough
– Fever/Chills
– Pleuritic chest pain
– Dyspnea
– Sputum production
– Some may have GI symptoms including nausea,
vomiting and diarrhea
• Physical Exam
– Fever
– Respiratory Rate >24
– Tachycardia
– Chest examination may reveal audible rales

4.  A chest radiograph should be obtained in
patients with suspected pneumonia when
possible; a demonstrable infiltrate by chest
radiograph or other imaging technique is
required for the diagnosis of pneumonia,
according to the 2007 consensus guidelines
from the Infectious Diseases Society of America
and the American Thoracic Society (IDSA/ATS)
 The radiographic appearance of Pneumonia
may include lobar consolidation, interstitial
infiltrates, and/or cavitation.

5. • The 2007 IDSA/ATS consensus guidelines
recommend for diagnostic testing:
– For outpatients with CAP routine diagnostic tests
are optional.
– Hospitalized patients should have CBC w/ diff,
blood cultures and sputum Gram stain and
culture
– Patients with severe CAP requiring ICU admission
should have blood cultures, urinary antigen tests,
and sputum culture (either expectorated or
endotracheal aspirate)

6.  There are a Severity-of-illness scores that can
help guide whether to admit or not but should
not be used over clinical judgment of the
patient and situation.
 CURB-65 criteria (>2, more-intensive
treatment)
 Confusion
 Urea 7 mmol/L (20 mg/dL)
 Increased respiratory rate >30
 low blood pressure (SBP <90 or DBP <60)
 Pneumonia Severity Index (PSI)
 uses demographics, the coexistence of co-
morbid illnesses findings on physical
examination, vital signs and essential
laboratory findings

7. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults
with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med
2005; 171:388.

8. • No known risk factors for multidrug-resistant
pathogens, early onset, and any disease severity
– Streptococcus pneumoniae
– MSSA
– Haemophilus influenzae
– Klebsiella pneumoniae
– Enterobacter
– Escherichia coli
– Acinetobacter
• Has risk factors for Multidrug resistant pathogens
– ESBL
– Legionella pneumophila
– MRSA
– P aeruginosa *** consider especially with VAP

9. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired,
ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171:388.

10. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-
acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171:388.

11.  If patient does not improve on broad
spectrum antibiotics may need to consider
possibilities including Fungal Pneumonias,
TB, PJP, Viral Pneumonias or even ARDs.

12.  Mandell LA, Wunderink RG, Anzueto A, et al.
Infectious Diseases Society of America/American
Thoracic Society consensus guidelines on the
management of community-acquired pneumonia in
adults. Clin Infect Dis 2007; 44 Suppl 2:S27.
 American Thoracic Society, Infectious Diseases
Society of America. Guidelines for the
management of adults with hospital-acquired,
ventilator-associated, and healthcare-associated
pneumonia. Am J Respir Crit Care Med 2005;
171:388.
 Schuetz P, Christ-Crain M, Thomann R, et al. Effect
of procalcitonin-based guidelines vs standard
guidelines on antibiotic use in lower respiratory
tract infections: the ProHOSP randomized
controlled trial. JAMA 2009; 302:1059.