health care associated pneumonia

1. Healthcare AssociatedHealthcare Associated
PneumoniaPneumonia
State Of Evidence To DateState Of Evidence To Date
Guide – Dr N T MinzGuide – Dr N T Minz
Presenter – Swayang Sudha PandaPresenter – Swayang Sudha Panda
Department of MedicineDepartment of Medicine

2. CLASSIFICATIONCLASSIFICATION
 Pneumonia is an infection of pulmonary parenchymaPneumonia is an infection of pulmonary parenchyma
 Traditionally pneumonia was classified asTraditionally pneumonia was classified as
CAP VAPCAP VAP
HAPHAP
CAP – Community Acquired PneumoniaCAP – Community Acquired Pneumonia
HAP – Hospital Acquired PneumoniaHAP – Hospital Acquired Pneumonia

3. However some patients presenting as outpatients
with onset of Pneumonia have been found to be
infected with Multi Drug Resistant (MDR) pathogens
previously associated with HAP
The potential involvement of of the MDR pathogens
has led to a new category of pneumonia term as
Health Care Associated Pneumonia (HCAP)

4. DefinitionsDefinitions

5. Community acquired pneumonia (CAP)Community acquired pneumonia (CAP)
Etiology -Etiology -
Outpatient
Hospitalised patient
Non ICU ICU
Streptococcus
pneumoniae
Streptococcus pneumoniea Streptococcus pneumoniea
Mycoplasma
pneumoniae
Mycoplasma pneumoniae Staphylococcus aureus
Haemophilus
influenzae
Chlamydia pneumoniae Legionella spp
Chlamydia
pneumoniae
Haemophilus influenzae Gram negative bacilli
Respiratory virus Legionella spp.
Respiratory virus
Haemophilus influenzae

6. Treatment of CAPTreatment of CAP
 OutpatientOutpatient
1)1) Previously healthy and no abx in past three months :- macrolide orPreviously healthy and no abx in past three months :- macrolide or
doxycyclinedoxycycline
2)2) Co morbidities or abx in past 3 months :-Co morbidities or abx in past 3 months :-
fluoroquinolone or beta lactam /cephalosporin +macrolidefluoroquinolone or beta lactam /cephalosporin +macrolide
 Inpatient ,non ICUInpatient ,non ICU
FluoroquinnoloneFluoroquinnolone
beta lactam /cephalosporin +macrolidebeta lactam /cephalosporin +macrolide
 Inpatient , ICUInpatient , ICU
beta lactam +beta lactam +
azithromycin or fluoroquinoloneazithromycin or fluoroquinolone
 If pseudomonas thenIf pseudomonas then
anti pseudomonal betea lactamanti pseudomonal betea lactam
Beta lactam +aminoglycosideBeta lactam +aminoglycoside
Betalactam+aminoglycoside+anti pseudomonal flourquinoloneBetalactam+aminoglycoside+anti pseudomonal flourquinolone
 If CA-MRSAIf CA-MRSA
Linezolide or vancomycinLinezolide or vancomycin

7. Ventilator associated pneumonia (VAP)Ventilator associated pneumonia (VAP)
EtiologyEtiology Non MDR pathogens MDR pathogens
Streptococcus pneumoniae P aeruginosa
Other streptococcus spp. MRSA
H. influenzae Acinatobacter spp.
MSSA Antibiotic resistant
enterobacteriaceae
Antibiotic sensitive
enterobateriaceae
Enterobacter spp.
E coli ESBL positive strains
K pneumoniae Klebseilla spp
Proteus spp. Legionella pneumoniae
Enterobacter spp. Burkholderia cepacia
Serratia marcescens Aspergillus spp

8. Hospital accquired pneumonia (HAP)Hospital accquired pneumonia (HAP)
 The etiology of HAP (inside and out side ICU) isThe etiology of HAP (inside and out side ICU) is
similar to VAP except for the fact that there issimilar to VAP except for the fact that there is
higher prevalence of non MDR pathogens and thehigher prevalence of non MDR pathogens and the
underlying host immunity is better in non intubatedunderlying host immunity is better in non intubated
patient.patient.
 Only pathogens more common in non VAPOnly pathogens more common in non VAP
population are anaerobes because of the greaterpopulation are anaerobes because of the greater
risk of aspiration in non intubated patient and lowrisk of aspiration in non intubated patient and low
oxygen tension in the respiratory tract of theseoxygen tension in the respiratory tract of these
patientpatient

9. Treatment for VAP/HAPTreatment for VAP/HAP
 Patient without risk for MDR pathogensPatient without risk for MDR pathogens
Ceftriaxone orCeftriaxone or
Moxi/cipro/levo- floxacin orMoxi/cipro/levo- floxacin or
Ampicillin/sulbactam orAmpicillin/sulbactam or
ErtapenemErtapenem
 Patient with risk factor for MDRPatient with risk factor for MDR
Beta lactam (ceftazidime or cefipime or P/T, meropenem or imipenemBeta lactam (ceftazidime or cefipime or P/T, meropenem or imipenem
Aminoglycoside active against gram negetive bacterial pathogenAminoglycoside active against gram negetive bacterial pathogen
(gentamycin/tobramycin) or(gentamycin/tobramycin) or
Levofloxacin/ciproflxacinLevofloxacin/ciproflxacin
Agent active gram positive bacterial pathogenAgent active gram positive bacterial pathogen
linezolidelinezolide
vancomycinvancomycin
THE LOWER FREQUENCY OF MDR PATHOGEN IN HAP ALLOWS FOR TREATMENT WITHTHE LOWER FREQUENCY OF MDR PATHOGEN IN HAP ALLOWS FOR TREATMENT WITH
MONOTHERAPYMONOTHERAPY

10. Concept of HCAPConcept of HCAP
 HCAP represents the subgroup of patients withHCAP represents the subgroup of patients with
ongoing contact with healthcare which places themongoing contact with healthcare which places them
at increased risk of infection with potentiallyat increased risk of infection with potentially
resistant pathogen likeresistant pathogen like Pseudomonas aeruginosa
andand Methicillin resistant Staph. aureus
 HCAP bridges what was thought to be a clearHCAP bridges what was thought to be a clear
divide between CAP and HAPdivide between CAP and HAP

11. Definition of Healthcare Associated PneumoniaDefinition of Healthcare Associated Pneumonia
ATS/IDSA Guidelines 2005ATS/IDSA Guidelines 2005
HCAP is defined based on the presence of one of theHCAP is defined based on the presence of one of the
following risk factorsfollowing risk factors
 Hospitalization for 2 days or more in the preceding 90 daysHospitalization for 2 days or more in the preceding 90 days
 Residence in the Nursing Home or Extended Care FacilityResidence in the Nursing Home or Extended Care Facility
 Home infusion therapy ( including antibiotics)Home infusion therapy ( including antibiotics)
 Chronic dialysis within 30 daysChronic dialysis within 30 days
 Home wound careHome wound care
 Family member with a MDR pathogenFamily member with a MDR pathogen

12. Why patients with HCAP are at anWhy patients with HCAP are at an
increased risk ?increased risk ?
 Due to infection with potentially resistant organismsDue to infection with potentially resistant organisms
 Due to failure to appreciate shifting pattern inDue to failure to appreciate shifting pattern in
epidemiology the patient receive empiricalepidemiology the patient receive empirical
antibiotics which are not active against culpritantibiotics which are not active against culprit
pathogenspathogens

13. Aetiolgy of HCAPAetiolgy of HCAP
CONDITION MRSA Pseudomonas
aeruginosa
Acinetobacter
spp
MDR
Enterobacteriaceae
Hospitalization for >=48 hr Y Y Y Y
Hospitalization for >=2
days in prior 3 months
Y Y Y Y
Nursing Home or
Extended Care Facility
residence
Y Y Y Y
Antibiotic Tx in
preceeding 3 months
Y Y
Chronic dialysis Y
Home infusion thrapy Y
Home wound care Y
Family member with
MDR infection
Y Y

14. Etiology of HCAP – more similar toEtiology of HCAP – more similar to
HAP than CAPHAP than CAP

15.  There is high variability in the etiology of HCAPThere is high variability in the etiology of HCAP
according to the sub group of patientaccording to the sub group of patient
 There is also high prevalence of MDR organisms inThere is also high prevalence of MDR organisms in
patient with HCAPpatient with HCAP
So this calls for an antibiotic therapy with a very broadSo this calls for an antibiotic therapy with a very broad
spectrum so as to cover the variety of pathogens inspectrum so as to cover the variety of pathogens in
patients presenting with HCAP and also to keep inpatients presenting with HCAP and also to keep in
mind the problem of MDR pathogensmind the problem of MDR pathogens

16. Debate regarding the concept of HCAPDebate regarding the concept of HCAP
 The empirical therapy for HCAP has a very broadThe empirical therapy for HCAP has a very broad
scectrumscectrum
 The potential size of the population pathogensThe potential size of the population pathogens
causing HCAP was hugecausing HCAP was huge
 Variable ability of the physicians to narrow theVariable ability of the physicians to narrow the
spectrum of therapy based on culture studiesspectrum of therapy based on culture studies
ALL THESE POINTS QUESTION THE ABILITY OF THE CRITERIA OFALL THESE POINTS QUESTION THE ABILITY OF THE CRITERIA OF HCAPHCAP TOTO
CORRECTLY IDENTIFY PATIENT WITH POTENTIALLY RESISTANT ORGANISMCORRECTLY IDENTIFY PATIENT WITH POTENTIALLY RESISTANT ORGANISM

17. Studies On HCAPStudies On HCAP
 So various studies have been done to understand theSo various studies have been done to understand the
complexities of the clinical entity HCAPcomplexities of the clinical entity HCAP
 Eight studies have described the epidemiology andEight studies have described the epidemiology and
outcomes of HCAP and CAP. Out of these 6 wereoutcomes of HCAP and CAP. Out of these 6 were
retrospective and 2 were prospective.6 were single centreretrospective and 2 were prospective.6 were single centre
and 2 were multi centre. All were performed between 2005and 2 were multi centre. All were performed between 2005
to 2010 with data collection between 2001 to 2010 . 4to 2010 with data collection between 2001 to 2010 . 4
required isolation of a pathogen (i.e culture positivity ) as anrequired isolation of a pathogen (i.e culture positivity ) as an
inclusion criteria while the rest enrolled patients meetinginclusion criteria while the rest enrolled patients meeting
clinical and radiological criteria for pneumonia regardless ofclinical and radiological criteria for pneumonia regardless of
culture findingculture finding

18. Author geography centers Design Culture total
Kollef et al USA Multi RC y 4543
Micek et al USA single RC y 639
Carratala et al Spain single PC n 727
Shindo et al Japan single RC y 371
Venditti et al Italy multi PC n 362
Schieber et al USA single RS y 190
Seki et al Japan single RS y 34
Park et al Korea single RS y 345

19.  Each study applied a set of risk factors adaptedEach study applied a set of risk factors adapted
from ATS/IDSA and recent hospitalization as thefrom ATS/IDSA and recent hospitalization as the
most consistently used criteriamost consistently used criteria
 All studies utilized various measures to assess theAll studies utilized various measures to assess the
illness severity including Pneumonia Severity Indexillness severity including Pneumonia Severity Index
(PSI), a modification of CURB-65 and the need for(PSI), a modification of CURB-65 and the need for
mechanical ventilationmechanical ventilation

20. The graph shows higher incedence of MRSA and Pseudomonas aeruginosa in
HCAP

21. This graph shows the proportion of patient receiving in appropriate antibiotic therapy in each
case

22. Inferences from the studiesInferences from the studies
 MRSA and Pseudomonas aeruginosa are mostMRSA and Pseudomonas aeruginosa are most
common in HCAP. And as there is variationcommon in HCAP. And as there is variation
between the prevalence of the pathogens in bothbetween the prevalence of the pathogens in both
the groups so is the variation between the severitythe groups so is the variation between the severity
the diseasesthe diseases
 the need for mechanical ventilation varied betweenthe need for mechanical ventilation varied between
3.2% to 100% in HCAP and 4.7% to 100% in CAP3.2% to 100% in HCAP and 4.7% to 100% in CAP
 The risk of receiving inappropriate antibiotic therapyThe risk of receiving inappropriate antibiotic therapy
was higher in HCAP than in CAPwas higher in HCAP than in CAP

23.  There is relative prolongation of hospital stay in HCAPThere is relative prolongation of hospital stay in HCAP
as compared to CAPas compared to CAP
 The crude mortality in HCAP was higher in comparisonThe crude mortality in HCAP was higher in comparison
to CAPto CAP
So the conclusion being HCAP is a separate entitySo the conclusion being HCAP is a separate entity
from CAP with higher severity of illness, higher risk offrom CAP with higher severity of illness, higher risk of
infection with MDR pathogen and is associated withinfection with MDR pathogen and is associated with
higher risk of being treated with an inappropriatehigher risk of being treated with an inappropriate
antibiotic therapy hence is associated with 2 fold higherantibiotic therapy hence is associated with 2 fold higher
mortalitymortality

24. On going controversiesOn going controversies
 How well does the definition of HealthcareHow well does the definition of Healthcare
associated pneumonia perform?associated pneumonia perform?
The studies have shown that the crieteria of HCAPThe studies have shown that the crieteria of HCAP
underperforms in this vein with a sensitivity ofunderperforms in this vein with a sensitivity of
78.3% and a specificity of 56.2%78.3% and a specificity of 56.2%
The studies also sought to devlop an appropriateThe studies also sought to devlop an appropriate
tool for screening of HCAP and developed a scoringtool for screening of HCAP and developed a scoring
system based on 3 criteriassystem based on 3 criterias

25. 1.1. Immunosupression (3 points)Immunosupression (3 points)
2.2. Admission from long term care (2 points)Admission from long term care (2 points)
3.3. Recent antibiotic exposure (1 point)Recent antibiotic exposure (1 point)
A total of 6 pointsA total of 6 points
Testing this score and its ability to detect patients with infectionTesting this score and its ability to detect patients with infection
revealed that a direct relationship between the score andrevealed that a direct relationship between the score and
frequency of infection with MRSA, Pseudomonas aeruginosa andfrequency of infection with MRSA, Pseudomonas aeruginosa and
pathogens producing extended spectrum Beta Lactamases. Thepathogens producing extended spectrum Beta Lactamases. The
risk of infection with an resistant organisms was 40% in patientrisk of infection with an resistant organisms was 40% in patient
with a score >2with a score >2
This signifies the need of development of better diagnostic tool toThis signifies the need of development of better diagnostic tool to
stratify patient presenting with pneumoniastratify patient presenting with pneumonia

26.  The problem of culture positivityThe problem of culture positivity
Since the rate of culture positivity Is generally lessSince the rate of culture positivity Is generally less
than 50% the use of HCAP as a concept will lead tothan 50% the use of HCAP as a concept will lead to
overuse of broad spectrum antibiotics and add to theoveruse of broad spectrum antibiotics and add to the
problem of microbial resistance.problem of microbial resistance.
Reassuringly the studies have found that despiteReassuringly the studies have found that despite
higher prevalence of treatment concordant for CAP inhigher prevalence of treatment concordant for CAP in
patient with culture negative HCAP the mortality waspatient with culture negative HCAP the mortality was
not much high in this group in comparision to thenot much high in this group in comparision to the
culture positive HCAPculture positive HCAP

27.  Since to date there is no reliable way to determineSince to date there is no reliable way to determine
at the outset of treatment which patient will beat the outset of treatment which patient will be
culture positive and which patient will be cultureculture positive and which patient will be culture
negative it appears prudent to apply HCAPnegative it appears prudent to apply HCAP
definition to rapidly identify patient with resistantdefinition to rapidly identify patient with resistant
organism and begin treatment for HCAP.organism and begin treatment for HCAP.
 Then this should be followed by an effort toThen this should be followed by an effort to
deescalate the initial therapy in response to thedeescalate the initial therapy in response to the
culture resultsculture results

28.  It has been observed in the studies that treating aIt has been observed in the studies that treating a
patient eventually classified as culture negativepatient eventually classified as culture negative
HCAP according to CAP guideline does notHCAP according to CAP guideline does not
necessarily harm the patientnecessarily harm the patient
 Thus a broad spectrum regimen for HCAP shouldThus a broad spectrum regimen for HCAP should
be started and by day 3 if no microbiologic databe started and by day 3 if no microbiologic data
exists to facilitate de-escalation the antibioticexists to facilitate de-escalation the antibiotic
regimen might be narrowed down to a CAP likeregimen might be narrowed down to a CAP like
regimen with a narrower spectrumregimen with a narrower spectrum

29.  Guideline concordant treatmentGuideline concordant treatment
The studies have shown though 79% of the patientThe studies have shown though 79% of the patient
admitted under CAP were treated with guidelineadmitted under CAP were treated with guideline
concordant regimen only 9% of the patient admittedconcordant regimen only 9% of the patient admitted
under HCAP were treated with guideline concordantunder HCAP were treated with guideline concordant
regimen despite the 71% of the participants beingregimen despite the 71% of the participants being
familiar with and in agreement with the HCAPfamiliar with and in agreement with the HCAP
guidelinesguidelines

30.  But the assessment of the relationship between guidelineBut the assessment of the relationship between guideline
discordant treatment and outcomes on a group of patientsdiscordant treatment and outcomes on a group of patients
from nursing home care facility with pneumonia has shownfrom nursing home care facility with pneumonia has shown
that there is not much difference patients being treated withthat there is not much difference patients being treated with
HCAP vs. CAP algorithmHCAP vs. CAP algorithm
 But again this might be due toBut again this might be due to
1. culture negative HCAP which might be treated1. culture negative HCAP which might be treated
successfully by CAP regimen orsuccessfully by CAP regimen or
2. the local prevalence of resistant organism being low2. the local prevalence of resistant organism being low
obviated the need for an anti biotic with broader spectrumobviated the need for an anti biotic with broader spectrum

31. DiagnosisDiagnosis
• Pneumonia should be suspected in patients with a new orPneumonia should be suspected in patients with a new or
progressive infiltrate on lung imaging and clinical characteristicsprogressive infiltrate on lung imaging and clinical characteristics
such as:such as:
• FeverFever
• Purulent sputumPurulent sputum
• LeukocytosisLeukocytosis
• Decline in oxygenationDecline in oxygenation
• Radiographic findings plus two of the clinicalRadiographic findings plus two of the clinical findings.findings.
• 69% sensitivity and 75% specificity for pneumonia.69% sensitivity and 75% specificity for pneumonia.

32. DiagnosisDiagnosis
• Comprehensive medical history and examinationComprehensive medical history and examination
• Gram staining and culture of sputum – main purpose of gramGram staining and culture of sputum – main purpose of gram
stain is to ensure that the sample is suitable for culture. To bestain is to ensure that the sample is suitable for culture. To be
adequate for culture a sputum sample should contain >25adequate for culture a sputum sample should contain >25
neutrophils and <10 squamous cell. For patient admitted to theneutrophils and <10 squamous cell. For patient admitted to the
ICU a deep suction aspirate or a broncho-alveolar lavageICU a deep suction aspirate or a broncho-alveolar lavage
sample may give an high yeild in culturesample may give an high yeild in culture
• Blood culture – though the yeild is low it should be collectedBlood culture – though the yeild is low it should be collected
before the initiation of the antibiotic therapybefore the initiation of the antibiotic therapy

33. • Antigen tests - to exclude Pneumococci andAntigen tests - to exclude Pneumococci and
legionella speiceslegionella speices
• Serology – this my aid to exclude atypicalSerology – this my aid to exclude atypical
antigen like Mycoplasma, Coxiella,legionellaantigen like Mycoplasma, Coxiella,legionella
• Polymerase chain reactionPolymerase chain reaction
• Chest x-ray (preferably PA and Lat) to identifyChest x-ray (preferably PA and Lat) to identify
infiltrate and possible complication such asinfiltrate and possible complication such as
effusion or cavitationseffusion or cavitations
•Arterial oxygenation saturation +/- ABGArterial oxygenation saturation +/- ABG

34. • A lower respiratory tract culture needs to beA lower respiratory tract culture needs to be
collected from all patients before antibioticcollected from all patients before antibiotic
therapy, but collection of cultures should nottherapy, but collection of cultures should not
delay the initiation of therapy in critical illdelay the initiation of therapy in critical ill
patients.patients.
• semi quantitative or quantitative culture datasemi quantitative or quantitative culture data
can be used for management of patients withcan be used for management of patients with
HCAPHCAP

35. DiagnosisDiagnosis
• Quantitative cultures increase specificity of theQuantitative cultures increase specificity of the
diagnosisdiagnosis
• Negative lower respiratory tract cultures can beNegative lower respiratory tract cultures can be
used to change antibiotic therapy in a patient toused to change antibiotic therapy in a patient to
a CAP like regimena CAP like regimen

36. When to suspect Risk for Resistant PathogenWhen to suspect Risk for Resistant Pathogen
 Knowledge of prior admissionKnowledge of prior admission
 Receipt of antibiotic therapyReceipt of antibiotic therapy
 Known MDR pathogen circulating in community or hospitalKnown MDR pathogen circulating in community or hospital
 Immunosuppressive disease present or therapy givenImmunosuppressive disease present or therapy given

37. Assesing the severity and requirementAssesing the severity and requirement
of hospital admissionof hospital admission
 Can be done byCan be done by
1.1. CURB 65CURB 65
2.2. PSIPSI
3.3. ATS guidelinesATS guidelines

38. CURB 65CURB 65
 C – ConfusionC – Confusion
 U - Blood Urea Nitrogen >19mg/dl or 7mmol/lU - Blood Urea Nitrogen >19mg/dl or 7mmol/l
 R - Respiratory rate >= 30R - Respiratory rate >= 30
 B - SBP < 90 mm of Hg or DBP < 60 mm of HgB - SBP < 90 mm of Hg or DBP < 60 mm of Hg
 Age >= 65 yrsAge >= 65 yrs
for each point the score is 1for each point the score is 1
Score Group Mortality Management
0-1 1 1.5% Out patient
2 2 9.2% Brief inpatient
3-5 3 22% ICU

39. ATS criteriaATS criteria
 MINORMINOR
1)1) RR >30RR >30
2)2) PaO2/FiO2 ratio < 250PaO2/FiO2 ratio < 250
3)3) Multilobar radiographic in volvementMultilobar radiographic in volvement
4)4) Uremia (BUN >20 mg/dl)Uremia (BUN >20 mg/dl)
5)5) Leucopenia (WBC count < 4000/dl)Leucopenia (WBC count < 4000/dl)
6)6) Thrombocytopenia (Plt count < 1 lakh/dl)Thrombocytopenia (Plt count < 1 lakh/dl)
7)7) Hypothermia (core temperature < 35 degree C)Hypothermia (core temperature < 35 degree C)
8)8) Hypotension requiring aggressive fluid resuscitationHypotension requiring aggressive fluid resuscitation
 MAJORMAJOR
1)Invasive mechanical ventilation1)Invasive mechanical ventilation
2)Septic shock with need for vassopressor2)Septic shock with need for vassopressor
ICU ADMISSION IF THREE MINOR OR ONE MAJOR CRITERIA ARE METICU ADMISSION IF THREE MINOR OR ONE MAJOR CRITERIA ARE MET

40. Pneumonia Severity Index (PSI)Pneumonia Severity Index (PSI)
points
Demographic factors male Age in yrs
female Age in yrs - 10
Nursing home resident Age in yrs + 10
Comorbid illness Neoplastic disease +30
Liver disease +20
CHF +10
Cerebrovascular disease +10
Renal disease +10

41. PSI (cont….)PSI (cont….)
Points
Physical examinaton
finding
Altered mental status +20
Respiratory rate >30 +20
SBP < 90 mm of Hg +20
Temp < 35 ◦C or > 40◦C +15
Pulse Rate >= 125 +10
Laboratory finding pH < 7.35 +30
BUN > 10.7 +20
Na < 130 mEq +20
Glucose > 250 mg/dl +10
Hematocrit < 30 +10
pO2<60 or SpO2<90 +10
Pleural effusion +10

42. score class Mortality( 30 days) management
< 70 I or II <1% OPD
71-90 III 2.8% Clinical judgement
91-130 IV 8.2-9.3% hospitalization
>130 V 31.1% hospitalization

43. Recommended empirical therapy forRecommended empirical therapy for
HCAPHCAP
 Combination therapy withCombination therapy with
antipseudomonal cephalosporin or a carbapenem orantipseudomonal cephalosporin or a carbapenem or
a beta–lactam/beta-lactamase inhibitora beta–lactam/beta-lactamase inhibitor
PLUSPLUS
antipseudomonal floroquinolone or aminoglycosideantipseudomonal floroquinolone or aminoglycoside
 Linezolide/vancomycin should be added to thisLinezolide/vancomycin should be added to this
combination if risk of MRSA is highcombination if risk of MRSA is high

44. Antibiotic Treatment of HCAPAntibiotic Treatment of HCAP

48. Four Major Principles Underlie the ManagementFour Major Principles Underlie the Management
of HCAPof HCAP
 Avoid untreated or inadequately treated HCAP, failureAvoid untreated or inadequately treated HCAP, failure
to do so is a consistent factor associated withto do so is a consistent factor associated with
increased mortality.increased mortality.
 Recognize the variability of bacteriology from oneRecognize the variability of bacteriology from one
hospital to another, one department from another andhospital to another, one department from another and
one time period to another.one time period to another.
 Avoid the overuse of antibiotics by focusing onAvoid the overuse of antibiotics by focusing on
accurate diagnosis, tailoring therapy and limit durationaccurate diagnosis, tailoring therapy and limit duration
of therapy to the minimal effective period.of therapy to the minimal effective period.
 Apply prevention strategies aimed at modifiable riskApply prevention strategies aimed at modifiable risk
factors.factors.

49. SummarySummary
 HCAP is a separate entity than CAPHCAP is a separate entity than CAP
 Etiology of HCAP is more similar to that of HAP/VAPEtiology of HCAP is more similar to that of HAP/VAP
 Patients with are more likely to harbor MDR organisms thanPatients with are more likely to harbor MDR organisms than
CAPCAP
 Patients with HCAP are more likely to get inappropriatePatients with HCAP are more likely to get inappropriate
antibiotic therapyantibiotic therapy
 The chance of developing resistance , length of hospital stayThe chance of developing resistance , length of hospital stay
and mortality is higher in HCAPand mortality is higher in HCAP
 in case of suspicion of HCAP, it should be treated with broadin case of suspicion of HCAP, it should be treated with broad
spectrum antibiotic after sending a culture. Then from thespectrum antibiotic after sending a culture. Then from the
third day onward effort should should be made to descalatethird day onward effort should should be made to descalate
the antibiotic therapy depending on the culture report i.e athe antibiotic therapy depending on the culture report i.e a
narrow spectrum antibiotic against the culprit pathogennarrow spectrum antibiotic against the culprit pathogen
should be used if culture positive or treatment concordantshould be used if culture positive or treatment concordant
with CAP can be used if culture negativewith CAP can be used if culture negative

50. THANK YOUTHANK YOU