1. HOSPITAL ACQUIRED
PNEUMONIA
BY
DR MUHAMMAD
AKRAM

2. PNEUMONIA
 Infection of the alveoli, distal airways, and
interstitium.

3. S&S OF PNEUMONIA
 Cough
 Tachycardia HR > 100
 Tachypnea RR > 20
 Fever T >37.8C
 At least one abnormal chest findings
- diminished breath sounds, rhonchi, crackles or wheeze
 New x-ray infiltrate with no clear alternative such as lung
cancer or pulmonary edema

4. CHEST RADIOGRAPH
 Confirm the
diagnosis of
pneumonia
 Assess severity of
disease and
presence of
complication

5. CLASSIFICATION (OLD)
 Community acquired pneumonia (CAP)
- Typical
- Atypical
*Aspiration
 Hospital Acquired (NOSOCOMIAL)
Pneumonia (HAP)
- Early onset
- Late onset
- Ventilator associated

6. CURRENT
CLASSIFICATION
 Community acquired pneumonia (CAP)
 Health Care-Associated Pneumonia (HCAP)
- Hospital-Acquired Pneumonia (HAP)
- Ventilator-Associated pneumonia (VAP)

7. DEFINITIONS
 Health Care-Associated Pneumonia (HCAP)
- Hospitalization for 2 or more days within 90 days of the
present infection
- Resident of a nursing home or long-term care facility
- Received recent IV antibiotic therapy, chemotherapy or
wound care in the past 30 days of the current infection
- Attended a hospital or hemodialysis clinic

8. DEFINITIONS
 Hospital Acquired Pneumonia (HAP)
-Defined as pneumonia that occurs 48 hours
or more after admission, which was not
incubating at the time of admission

9. DEFINITIONS
 Ventilator Associated Pneumonia (VAP)
- Pneumonia that arises more than 48-72
hours after endotracheal intubation

10. EPIDEMIOLOGY
 HAP is the second most common nosocomial infection in the United
States.
 It carries an associated mortality rate of 30% to 70%.
 HAP lengthens the hospital stay by 7 to 9 days and is associated with a
higher cost of medical care.
 HAP is the most common infection occurring in patients requiring care in
an intensive care unit (ICU)
 This increased incidence is because patients located in an ICU often
require mechanical ventilation, and mechanically ventilated patients are
6 to 21 times more likely to develop HAP than nonventilated patients.
 Mechanical ventilation is associated with high rates of HAP
 The development of HAP in mechanically ventilated patients portends a
poor prognosis, with a rate of mortality 2 to 10 times higher for this
group than for mechanically ventilated patients without HAP.

11. PATHOGENESIS
 Gram-negative bacteria (Pseudomonas,K.Pneumonia,
H.Influenza.Acenatobacter…) account for 55% to 85%
of HAP infections, and gram-positive cocci (Staph
and Streptococci)account for 20% to 30%.
 Microaspiration of contaminated oropharyngeal
secretions is the most common cause of HAP
 The oropharynx of hospitalized patients becomes
colonized by GNB in as many as 35% of moderately ill
and 73% of critically ill patients, often within the first 4
days of admission.

12. PATHOGENESIS
 Colonization of the oropharynx with
pathogenic microorganisms
 Aspiration from the oropharynx into the lower
respiratory tract
 Compromise of the normal host defense
mechanisms

13. MICROBIOLOGIC CAUSES OF
HCAP
Non-MDR Pathogens MDR Pathogens
Streptococcus pneumoniae Pseudomonas aeruginosa
Other Streptococcus spp. MRSA
Haemophilus influenzae Acinetobacter spp.
Escherichia coli
Klebsiella pneumoniae Klebsiella spp.
Proteus spp. Legionella
pneumophila
Enterobacter spp. Burkholderia cepacia
Serratia marcescens Aspergillus

14. Risk factors for hospital-acquired pneumonia
Intrinsic risk factors Extrinsic risk factors
 Age 60-65 yr  Supine position
 Gender: male  Nasogastric tube
 Season: fall, winter  Enteral nutrition
 Prolonged mechanical  Re-intubation
ventilation  Tracheotomy
 APACHE II score 16-20  Intra-cuff pressure <20
 Coma cmH2O
 Aspiration  Gastric alkalization
 COPD/pulmonary disease  Heated humidifiers (open
 Surgery systems)
 Organ system failure index 3
of 7

15. RISK FACTORS FOR MULTIDRUG-
RESISTANT PATHOGENS
 Antimicrobial therapy was initiated within the
preceding 90 days.
 Onset of pneumonia occurred after 4 days of
hospitalization.
 Known MDR pathogens are circulating in the
community or hospital.
 Immunosuppressive disease is present or
immunosuppressive therapy has been initiated.
 Increased use of outpatient IV antibiotic therapy
 General aging of the population

16. HAP RISK INDEX
 Pao2/Fio2 = ratio of arterial O2 pressure to
fraction of inspired O2; ARDS = acute
respiratory distress syndrome.
 *Criteria applicable 72 h after initial diagnosis.
 Score ≥ 6 suggests hospital-acquired
pneumonia.
 Score < 6 suggests alternative process.
American Journal of Respiratory and Critical Care Medicine 162:505–511, 2000.

17. HOSPITAL ACQUIRED PNEUMONIA RISK INDEX
Factor Points
Temperature (°C)
≥ 36.5 and ≤ 38.4 0
≥ 38.5 and ≤ 38.9 1
≥ 39 and ≤ 36 2
Blood leukocytes, μL
≥ 4,000 and ≤ 11, 000 0
< 4,000 or > 11,000 1
Band forms ≥ 50% 1
Tracheal secretions
None 0
Nonpurulent 1
Purulent 2
Oxygenation: Pao2/Fio2, mm Hg
> 240 or ARDS 0
≤ 240 and no ARDS 2
Pulmonary radiography
No infiltrate 0
Diffuse (or patchy) infiltrate 1
Localized infiltrate 2
Progression of infiltrate*
None 0
Progression (heart failure and ARDS excluded) 2
Growth of pathogenic bacteria on tracheal aspirate
culture*
No, rare, or light growth 0
Moderate or heavy growth 1
Same bacteria as on Gram stain 1

18. DIAGNOSTIC TESTS
 Blood Cultures: gold standard
 Gram stain and cultures of
appropriate pulmonary secretions
 Serology
 PCR
 Urine antigen test
 Direct antibody test

19. DIAGNOSTIC TESTS
 Blood Culture
- Only 5-14% of cultures of blood are positive
- No longer considered necessary for all
hospitalized CAP patients
- Should be done in certain high-risk patients
(i.e. severe CAP; chronic liver disease

20. DIAGNOSTIC TESTS
 Sputum Culture
- Sensitivity and specificity is highly variable
(< 50%)
- Greatest benefit is to alert the physician of
unsuspected and/or resistant pathogens

21. DIAGNOSTIC TESTS
 Gram Stain
- May help identify pathogens by their
appearance

22. DIAGNOSTIC TESTS
 Antigen tests
- Two commercially available tests detect
pneumococcal and Legionella antigens in urine
- Sensitivity and specificity are high for both
tests
- Can detect antigen even after the initiation of
appropriate antibiotic therapy
- Limited availability

23. DIAGNOSTIC
TESTS
 SPUTUM DIRECT FLUORESCENT
ANTIBODY (DFA)
 A test that looks for microorganisms in
lung secretions
 Abnormal results may be due to an
infection such as Legionnaire's disease,
mycoplasma pneumonia , or chlamydia
pneumonia.

24. GENERAL CONSIDERATIONS
 Adequate hydration
 Oxygen therapy for hypoxemia
 Assisted ventilation when necessary

25. EMPIRICAL ANTIBIOTIC TREATMENT
OF HCAP
 PATIENTS W/O RISK FOR MDR
PATHOGENS
- Ceftriaxone 2g IV q24 hours or
- Moxifloxacin 400mg IV q24 hours,
Ciprofloxacin 400mg IV q8 hours,
Levofloxacin 750mg IV q24 hours or
- Ampicillin/Sulbactam 3 gm IV q6 hours or
- Ertapenem 1gm IV q24 hours

26. EMPIRICAL ANTIBIOTIC TREATMENT
OF HCAP
 PATIENTS WITH RISK FOR MDR PATHOGENS
1. A beta-lactam:
Ceftazidime 2 gm IV q8 hours or Cefepime 2 gm IV q8-q12 hours or
Piperacillin/Tazobactam 4.5 gm IV q6 hours, Imipinem 500mg IV q6
hours or 1 gm IV q8 hours, Meropenem 1 gm IV q8 hours plus
2. A second agent active against gram-negative bacterial pathogens:
Gentamicin or Tobramycin 7 mg/kg IV q24 hours or Amikacin 20 mg/kg
IV q24 hours or
Ciprofloxacin 400mg IV q8 hours or Levofloxacin 750mg IV q24 hours
plus
3. An agent active against gram-positive bacterial pathogens:
Linezolid 600 mg IV q 24 hours or
Vancomycin 15mg/kg q12 hours
Adapted from Niederman MS, Craven DE, Bonten MJ, et al: Guidelines for the management of adults with
hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care
Med 2005;171:388-416.

27. STREAMLINING OF EMPIRIC ANTIBIOTIC
THERAPY
Switch of oral antibiotic agent
1. There is less cough and resolution of respiratory distress
(normalization of RR)
2. The patient is afebrile for > 24 hours.
3. The etiology is not a high risk (virulent/resistant) pathogen.
4. There is no unstable co-morbid condition or life-threatening
complication such as MI, CHF, complete heart block, new
atrial fibrillation, supraventricular tachycardia, etc.
5. There is no obvious reason for continued hospitalization
such as hypotension, acute mental changes, BUN: Cr of
>10:1, hypoxemia, metabolic acidosis, etc.

28. Rate of resolution of physical and
laboratory abnormalities
Abnormalities Duration
Fever 2 to 4 days
Cough 4 to 9 days
Crackles 3 to 6 days
Leukocytosis 3 to 4 days
C-reactive protein 1 to 3 days
CXR abnormalities 4-12 weeks
Patient is considered to have responded if:
1. Fever declines within 72 hrs
2. Temperature normalizes within 5 days
3. Respiratory signs (tachypnea) return to normal

29. Failure to improve within 48 to 72 hours
following therapy
 Noninfectious conditions
- Cancer, embolus, hemorrhage
 Resistant pathogen
 Wrong drug
 Right drug, wrong dose
 Unusual pathogens
- Mycobacterial, anaerobic(Bacteroides,
Actinomyces…) viral, fungal
 Nosocomial superinfections

30. FAILURE TO IMPROVE
 Due to MDR pathogens
 Reintroduction of the microorganisms
 Superinfection
 Extrapulmonary infections
 Drug toxicity

31. COMPLICATIONS
 Death
 Prolonged mechanical ventilation
 Prolonged hospital stay
 Development of necrotizing pneumonia
 Long-term pulmonary complications
 Inability of the patient to return to
independent function

32. PROGNOSIS
 HCAP is associated with significant mortality
(50%-70%)
 Presence of underlying diseases increases
mortality rate
 Causative pathogen also plays a major role

33. PREVENTION
 Decreasing likelihood of encountering the pathogen
- hand washing
- use of gloves
- Use of face mask
- Negative pressure room
- Prompt institution of effective chemotherapy for patients with
contagious illnesses
- Correction of condition that facilitate aspiration
- Maintenance of gastric acidity
- FOLLOW VAP PREVENTION PROTOCOLS
 Strengthening the host’s response once the pathogen is
encountered
- Chemoprophylaxis
- Immunizing of patients at risk

34. PATHOGENIC MECHANISMS AND
CORRESPONDING PREVENTION
STRATEGIES FOR VENTILATOR-ASSOCIATED
PNEUMONIA
Pathogenic Mechanism Prevention Strategy
Oropharyngeal colonization with
pathgenic bacteria
Elimination of normal flora Avoidance of prolonged antiobiotic
courses
Large-volume oropharyngeal
aspiration around time of Short course of prophylactic antibiotics
intubation for comatose patients
Gastroesophageal reflux Post pyloric enteral feeding;
Avoidance of high gastric residuals
Bacterial overgrowth of stomach Avoidance of gastrointestinal bleeding
due to prophylactic agents that raise
gastric pH; selective decontamination of
digestive tract with nonabsorbable
antibiotics

35. Pathogenic Mechanism Prevention Strategy
Cross-infection from other Hand washing, especially with alcohol
colonized patients based hand rub; intensive infection
control education; isolation; proper
cleaning of reusable equipment
Large-volume aspiration Endotracheal intubation; avoidance
of sedation; decompression of
small-bowel obstruction
Microaspiration around
endotracheal tube
Endotracheal intubation Noninvasive ventilation
Prolonged duration of Daily awakening from sedation
ventilation weaning protocols
Abnormal swallowing function Early percutaneous tracheostomy
Secretions pooled above Head of bed elevated; continuous
endotracheal tube aspiration of subglottic secretions

36. Pathogenic Mechanism Prevention Strategy
with specialized endotracheal tube
avoidance of reintubation;
minimization of sedation and
patient transport
Altered lower respiratory host Tight glycemic control; lowering of
defenses hemoglobin transfusion threshold;
specialized enteral feeding formula

37. REFRENCE
 Treatment of hospital-acquired, ventilator-associated, and healthcare-associated pneumonia in
adults UpToDate.com Octobar 2009
Author
Thomas M File, Jr, MD
 European Respiratory Society 2007
 Adapted from Singh N, Rogers P, Atwood CW, et al: Short-course empiric antibiotic therapy for
patients with pulmonary infiltrates in the intensive care unit. American Journal of Respiratory and
Critical Care Medicine 162:505–511, 2000.
 Hospital-Acquired Pneumonia by John G. Bartlett, MD, May 2008
 Hospital-Acquired, Health Care Associated, and Ventilator-Associated Pneumonia BY Justin L.
Ranes
Steven Gordon Alejandro C. Arroliga ,CLEVELAND CLINIC
 Hospital-acquired pneumonia: Epidemiology, etiology, and treatment. Infect Dis Clin North Am.
12: 1998; 761-779
 Hospital-acquired pneumonia: Risk factors, microbiology, and treatment. Chest. 119: 2001; 373S-
384S
 David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of
Medicine, University of Washington School of Medicine 5/23/2010