Hospital Acquired Pneumonia Lecture By: Dr .Mohammed Munir Khan Consultant pulmonologist MB, DTCD, DCard, DGM, MRCP,  FRCP (London), FRCP (Ire.)

1. In the name of Allah, the Most
Gracious, the Most Merciful

2. Hospital Acquired Infections
hospital acquired pneumonia, ventilator associated infections, surgical site
infections, blood stream infections, urinary catheter associated infections.
15% of above will get HAP
 Scale of the problem : 1% admissions will get HAP
 Increase length of stay expensive, need IV abx
 Increase morbidity
 High mortality 20—50 %

3. Dr .Mohammed Munir Khan
Consultant pulmonologist
MB, DTCD, DCard, DGM, MRCP,
FRCP (London), FRCP (Ire.)

6. Definition
 Pneumonia - Infection of the lung parenchyma with
symptoms and signs of consolidation of lung parenchyma.
 Hospital Acquired – Occurs 48 hours or more after
hospital admission

7. Clinical features
 Fever
 Productive cough, pleuritic chest pain, SOB.
 Raised inflammatory markers
 New CXR infiltrates
 Deterioration of gas exchange

8. Risk factors for HAP
 Pt related and environment related
 Age >70
 Severe underlying disease/co morbidities
 Malnutrition
 Immune compromised
 Coma
 Metabolic acidosis
 Sinusitis

9.  Infection control related :
 Poor healthcare worker hand hygiene
 Contaminated respiratory equipment

10.  Intervention related
 Sedatives
 Corticosteroids
 Cytotoxic drugs
 Prolong use of antibiotics
 Ventilations (risk 20 times greater )

11.  During pulmonary infection, acute inflammation results in
the migration of neutrophils (and other inflammatory
exudate) out of capillaries and into the air spaces, forming
a marginated pool of neutrophils.
 Neutrophils phagocytize microbes.
 Increased mucus production which can form mucus plug
 Alveoli fill with fluid (inflammatory
exudate/pus/blood/mucus)  consolidation

12. Pathophysiology
Extrinsic factors
 Exposure to causative agent
 Exposure to pulomary irritant
Intrinsic factors (host related)
 Pulmonary injury – COPD, bronchiectasis, CF, Ca
 Loss of protective airway reflexes – CVA, intoxication,
altered mental status, intubated
 Spread from upper airways/haematogenous spread
 Immunocompromised
Scale of the problem : 1% admissions will
get HAP
Increase length of stay
Increase morbidity
Increase complications
High mortality 20 to 50%

13. Investigations
CXR - non specific infiltrates
Blood, sputum and pleural fluid for culture
Arterial blood gas for severity
Renal and liver function tests to assess organ
dysfunction
Serology of little use in HAP

16. < 5 days
 S pneumoniae
 H Influnenzae
 S aureus
 Enterobacter spp

17. The same bugs?
 Different for CAP and HAP
 Different < 5 days in hospital
 > 5 days in hospital
 Unventilated and ventilated patients

18. > 5 days in hospital
 P. Aerugenosa
 Enterobacter spp.
 Acinobacter spp.
 Klebsiella spp.
 S macrescens
 E coli
 Other GNRs
 Saureus/ MRSA

19. Other special risks
 Anaerobic bacteria
 Legionella pneumophila
 Viruses : infuenza A and B, RSV
 Fungi

20. Antibiotics
 Early onset infection <5 days not severe Co Amoxicav
or Cefuroxime / ceftriaxome 7days
 Late onset > 5days anti pseudomonial penecillin or
Ceftazidime or quinolone
 For MRSA suspected Vencomycin
 Consider adding Aminoglycoside for severe illness
suggested duration 7 or longer if pseudomonas

21. VAP
Complicates the course 8—60 % on MV
Mortality from 15% to 50%

22. Pathogenesis /risk factors
 Intubation compromise s natural barrier between
oropharynx and trachea.
 Age>60, hypoalbu, ARDS, COPD, coma, burns,
trauma, organ failure, gastric aspiration, resp tract
colonization, sinusitis, H2 receptor antagonist,
paralytic agents, prior antibiotics, continued
sedation, MV >2days, tracheostomy, NG tube,
supine position.

23. Poor prognostic factors
 Age
 Co morbidities
 Presence of fever < 35 c > 40c
 Cvs HR >125/min low BP
 Resp Rate >/30/min
 Sats <90 %
 Metabolic urea Na 130 Glucose >250 pH
<7.35

24. V A P
 Local policies and advice from microbiology
 Drug resistant pathogens P aeruginosa, MRSA,
acinobactor, klebsiella.
 Delay in treatment not an option

25.  Summary
 Thanks