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Hospital Acquired Pneumonia (HAP)

-Pneumonia that occurs >/= 48 hours after hospital admission
-Not incubating at time of admission

Ventilator-Associated Pneumonia (VAP)

-Pneumonia that occurs >/= 48 hours after endotracheal (ET) intubation/mechanical ventilation

How to manage patients that require ET intubation after developing severe HAP?

Manage similar to VAP

Healthcare Associated Pneumonia (HCAP) Risk Factors

1) Patients have >/= 2 risk factors for MDR pathogen

2) Hospitalization in an acute care hospital for >/= 2 days within 90 days of current infection

3) Nursing home or long-term care facility resident

4) Within 30 days of current infection received
-Home infusion/IV antibiotic therapy
-Home wound care therapy
-Hemodialysis (HD) at a hospital/clinic

Early onset of pneumonia

-Occurs within the first 4 days of hospitalization

-More likely antibiotic sensitive pathogens

-Carries a better prognosis

Late onset of pneumonia

-Occurs on day 5 or later of hospitalization

-More likely MDR pathogens

-Associated with increase patient morbidity/mortality

Aerobic GNR pathogens

1) Pseudomonas aeruginosa
2) Acinetobacter sp
3) Stenotrophomnas maltophilia
4) Burkholderia cepacia
5) Klebsiella pneumoniae
6) Escherichia coli

7) Citrobacter sp
8) Enterobacter sp (eg. cloacae)
9) Proteus sp (eg. mirabilis)
10) Serratia marcescens

Aerobic GPC pathogens


2) Staphylococcus aureus
3) Streptococcus viridans
4) Staphylococcus epididemus
5) Neisseria sp
6) Corynebacterium sp (GPR)

Anaerobic GNR Pathogen


Multi-Drug resistance pathogens/ ESBL

1) Klebsiella pneumoniae
2) Escherichia coli

Risk factors for MDR pathogens

1) Antimicrobial therapy within past 90 days
2) Current hospitalization for >5days
3) High frequency of antibiotic resistane in community or in specific hospital unit
4) Presence of risk factors for HCAP
5) Family member with MDR pathogen
6) Immunosuppressive disease and/or therapy
7) Healthcare worker

Uncommon pathogen

1) anaerobes (aspiration)
2) Legionella pneumophila
3) Virus (primary viral infection) to secondary bacterial infection
4) Fungus

Where is legionella pneumophila transmitted?

1) Construction areas/excavation sites
2) inhalation of aerosols or microaspiration of contaminated water (air conditioners and showers)

Sources of microorganisms access to lower respiratory tract (LRT)

1) inhalation of aerosolized particles
2) Hematogenous spread from extrapulmonary sites of infection (rare)
3) Aspiration of oropharyngeal contents
4) Leakage of bacteria around endotracheal (ET) tube cuff
5) Healthcare devices or environment
6) transfer between staff and patients (Hand Hygiene)

What is the primary etiology of microorganism access to lower respiratory tract?

Aspiration of oropharyngeal contents

Patient related Risk factors

1) Gender (M>F)
2) Pre-existing pulmonary disease (asthma/COPD)
3) Multiple organ system failure

Treatment related risk factors

1) intubation
2) Enteral feeding

Modifiable risk factors

1) intubation and mechanical ventilation

2) ET tubes

3) Ventilation circuit

4) Supine vs. semi-recumbent positioning

5) Enteral nutrition

6) Modulation of oral colonization

7) Stress ulcer prophylaxis (SUP)

8) Blood transfusions

9) Tight glucose control: 80-110 mg/dL

10) strict infection control

Modifiable Risk Factors: intubation and mechanical ventilation

-noninvasive ventilation to avoid re-intubation
-Sedation/daily wake-up trials to facilitate weaning

Modifiable risk factors: ET tubes

-Oral ET & orogastric vs nasotracheal & NG tubes
-Aspiration of subglottic secretions may decrease HAP risk
-Limit sedatives & paralytic agents
-Maintain ET cuff pressure at >20 cm water

Modifiable risk factors: Ventilator circuit

-frequent changing- no affect on incidence of HAP
-Remove contaminated condensate from circuit

Modifiable risk factors: Supine vs. Semi-recumbent positioning

Semi-recumbent positioning (30-45 degree)

Modifiable risk factors:Enteral Nutrition

-Other risk with total parenteral nutrition (TPN)
-Post-pyloric feeding (decrease risk of aspiration)

Modifiable risk factors: Modulation of oral colonization

-Oral antiseptics: chlorhexidine
-Oral antiseptics: +/- systemic antibiotics
-Selective decontamination of digestive tract (SDD)

Modifiable risk factors: Stress ulcer prophylaxis (SUP)

Use H2RA or PPI instead of sucralfate because sucralfate doesn't affect pH but it increase the risk of bleeding

Modifiable risk factors: Tight glucose control

80-110 mg/dL

NICE-SUGAR: goal <180 mg/dL

Modifiable risk factors: Infection control

-Hand hygiene: soap and water, alcohol based hand disinfection
-contact precautions: gown, gloves

Key diagnosis points

1) Chest X-ray
2) LRT cultures

Suspicion of HAP: Want at least 2 of the finding

1) Radiologic infiltrate that is new or progressive
2) clinical findings suggestive of infection
-New onset of fever
-Purulent sputum
-Leukocytosis or leukopenia
-Decreased oxygenation

Clinical conditions leading to increased suspicion of PNA/warranting further diagnostic testing

-ARDS (acute respiratory distress syndrome)
-Pt w/ unexplained hemodynamic instability or deterioration of blood gases during mechanical ventilation

LRT culture from

1) Endotracheal (ET) aspirates
2) Protected specimen brush (PSB)
3) Bronchoalveolar lavage (BAL)

Consider nosocomial tracheobronchitis

When the following are present:
-Purulent sputum
-Sputum or tracheal aspirate culture (+)

But a new lung infiltrate is absent

Presence of pneumonia defined as:

New lung infiltrate
2 or 3 clinical features
-Leukocytosis or leukopenia
-purulent sputum

Management: clinical strategy

Emphasizes prompt empiric therapy for all patients suspected of having HAP

Management: Bacteriologic Strategy

Uses quantitative LRT cultures to define presence of pneumonia and etiologic pathogen

Don't start ABX till know what pathogen it is

Inappropriate empiric antimicrobial treatment (IEAT)

-use of ABX w/ poor or no in vitro activity against the identified infecting microorganism

-increasing antimicrobial resistance increases probability of IEAT

Empiric ABX therapy for HAP withOUT late onset or risk factor for MDR pathogens

Limited spectrum ABX therapy

Empiric ABX therapy for HAP WITH late onset or risk factor for MDR pathogens

Broad spectrum ABX therapy for MDR Pathogens

Initial empiric antibiotic therapy for HAP/VAP/HCAP with NO risk of MDR pathogen and it is Early onset of pneumonia

1) Ceftriaxone
2) FQ: LVQ, Moxi, Cipro
3) Ampicillin/Sulbactam
4) Ertapenem

Chose ONE

Initial empiric antibiotic therapy for HAP/VAP/HCAP with risk of MDR pathogen and it is LATE onset of pneumonia

One of these
1) Antipseudomonal Cephalosporin (Cefepime or Ceftazidime)
2) Antipseudomonal carbepenem (Imipenem or Meropenem)
3) Beta lactam/beta lactamase inhibitor (Piperacillin/tazobactam)

PLUS ONE of these:
1) Antipseudomonal FQ: (LVQ or Cipro)
2) AMG ( Amikacin or Gentamycin or Tobramycin)

PLUS ONE of these:
1) MRSA coverage: VAncomycin or Linezolid

IF suspect legionella pneumophila:
-substitute AMG for Macrolide (Zithromax)

DOC for Pseudomonas aeruginosa

1) Beta lactam + AMG
2) Beta lactam + FQ
3) Adjunctive inhaled ABX

DOC for Acinetobacter sp

1) Carbapenems (DOC) except ertapenem
2) ampicillin/sulbactam
3) Polymyxin


1) Carbapenem (DOC)
2) Caution/optimal doses
-4th generation cephalosporin


1) Vancomycin
2) Linezolid

Patient as risk for HCAP should be treated for potentially _______ organism.


Regardless of which hospital admission day pneumonia begins

What is most commonly associated with MDR organisms

Inappropriate empiric antibiotic treatment

Optimizing empiric ABX therapy: Key points

-Optimal doses of ABX should be used
-Route of administration: IV first, then PO
-Monotherapy w/ selected agents for severe HAP and VAP may be used in the absence of resistant pathogens
-MDR pathogens suspected : use combo therapy
-AMG included in empiric combo therapy: may d/c after 5-7 days in responding patietnts
-Duration of theapy may be shortened to 7 days if pt started on appropriate therapy and show clinical response and not pseudomonas aeruginosa.
-Aerosolized ABX: adjunctive therapy for GNRs, no proven valvue as mono therapy

Inclusion criteria for adjunctive aerosolized ABX therapy in VAP

1) Mechanical ventilation for >/= 48 hrs
2) VAP diagnosis q/ documented psudomonas aeruginosa, Acinetobacter baumanii, or both , which required aerosolized ABX

Exclusion criteria for adjunctive aerosolized ABX therapy in VAP

1) incomplete medical record
2) Pregnancy
3) Active malignancy or immmunosuppression
4) Received aerosolized ABX for </= 3 days

Advantages of adjunctive aerosolized ABX therapy in VAP

1) Achieve high concentrations of med at site of infection
2) typically have minimal systemic absorption

Adjunctive inhaled ABX administered

1) Tobramycin 300 mg inh q12hrs
2) Amikacin 1000 mg inh q 12 hrs
3) Colistimethate sodium: 150 mg inh q12 hours

Assessing response to therapy

1) Serial assessment of clinical response
-Repeat: CXR, Cultures, Tmax, WBC
-Adjust empiric therapy based on results and micro data

2) Clinical improvement usually takes 48-72 hrs

3) De-escalate ABX therapy in responding patients when allowed per culture data

4) non-responding patients require further evaluation and testing

Assessment of NOnresponders

1) Wrong organism
2) Wrong diagnosis
3) Complication

Assessment of Non-responders: Wrong organism

-Drug resistant pathogen baceria, mycobacteria, virus, fungus, inadequate antimicrobial therapy

Assessment of non-responders: Wrong diagnosis

Atelectasis, PE, ARDs, Pulmonary hemorrhage, underlying disease Neoplasm

Assessment of Non-responders: Complication

- Empyema or lung abscess
- C. difficille colitits
- occult infection
- drug fever


inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract (LRT)

Aspiration pneumonitis

-Acute chemical lung injury
-Caused by inhalation of sterile gastric contents

Aspiration pneumonia

-Infectious process
-caused by inhalation of oropharyngeal secretions colonized by pathogenic bacteria
-development of a radiographically evident infiltrate

What is the #1 cause of death in patients with dysphagia due to neurologic disorder?

Aspiration pneumonia

Risk factors for aspiration pneumonia

1) occurs w/ decreased level of consciousness
-Drug overdose
-Alcohol consumption
-Use of anesthesia/sedative
-Massive CVA

2) Elderly patients w/ increased of neurologic disease/dysphagia, poor dentition w/ increased colonization/Abnormal lower esophageal sphincter/GERD

3) Critically ill patients
4)Mechanical intubation

Signs/Symptoms of gastric acid aspiration

1) Coughing
2) SOB
3) Wheezing

4) Cyanosis
5) Pulmonary edema
7) Death

Damage due to aspiration pneumonitis is depends on what?

1) Acidity of refluxate
2) Volume aspirated
3) Particulate matter (eg. food)

Aspiration pneumonitis: Results in inflammatory reaction

Phase 1: Direct caustic effect of low pH/peaks in 1-2 hours

Phase 2: infiltration of neutrophils & inflammatory mediators into the alveoli and lung interstitium

When is empirical antibiotics appropriate in aspiration pneumonitis patients?

-Small bowel obstruction (SBO) or other conditions associated with gastric contents colonization
-Pneumonitis that fails to resolve within 48 hours

What should be consider when broad spectrum antibiotic is initiated?

-Perform BAL or PSB to determine organism
-Adjust antibiotic as appropriate

Corticosteroids is not recommended in ________________

Aspiration pneumonitis

Common organism in community setting

1) Strep. pneumoniae
2) Staph. aureus
3) Haemophilus influenzae
4) Enterobacteriaceae spp
5) Low incidence of anaerobes

Common organism in healthcare facility setting

1) Kleb. pneumo
2) E. coli
3) Serratia marcenscens
4) Ps. aeruginosa
5) Acinetobacter baumanii
6) Low incidence of anaerobes

Anaerobic coverage not required in aspiration pneumonia except in patient with what?

1) severe periodontal disease
2) Putrid sputum
3) Evidence of necrotizing PNA or lung abscess on CXR

Empiric ABX for Aspiration Pneumonia: pt with s/s lasting >48 hours

1) Ceftriaxone
2) Levofloxacin

Empiric ABX for Aspiration Pneumonia: pt with small bowel obstruction or use of antacids, anti-secretory agents

1) Ceftriaxone
2) Piperacillin/tazobactam
3) Levofloxacin
4) Ceftazidime
5) Ciprofloxacin

Empiric ABX for Aspiration Pneumonia NOT in healthcare facility setting

Levofloxacin OR ceftriaxone

Empiric ABX for Aspiration Pneumonia IN healthcare facility

1) Levofloxacin
2) Ceftazidime
3) Piperacillin/tazobactam

Prevention of Aspiration Pneumonia

1) modify: soft diet, reduce bite size
2)Mechanical ventilation, esp. w/ tube feeding
-Head of bed elevation: 30-45 degree
-Stress ulcer prophylaxis (SUP)
-Oral care
-Daily wake up trials/assessment

Prevention of Aspiration Pneumonia: Vaccinaiton

1) Pneumococcal Vaccine
-Pneumococcal polysaccharide (PPSV)
-Pneumococcal conjugate (PCV13)
-Reduce risk of invasive disease by 60-70%

Who should receive PPSV

1) Pt >/= 65 yo
2) pt 19-64 yo who smoke cigarettes, or have asthma
3) Pt 2-64 yo w/ chronic illness/high risk
-Pulmonary disease
-Cardiovascular disease
-metabolic (DM)
-renal dysfunction
-Hemoglobinopathies (sickle cell disease)

Who should re-administration of PPSV vaccine

-not required if pt was >/= 65 yo when receive first dose
-indicated in pt >/=65 yo if has been at least 5 years since initial vaccination dose
-pt 2-64 yo at highest risk of death who received initial dose >/= 5 years ago

Max dose of PPSV

2 dose

Who should receive PCV13

1) infant and children <2 yo
-routine schedule: 2,4,6, and 12-15 months
2) if received full dosing schedule w/ PCV7, should receive 1 dose of PCV13
-children 14-59 months of age w/ underlying medical condition

Prevention of Aspiration Pneumonia: influenza vaccine

-Trivalent inactivated influenza vaccine (TIV)
-Live attenuated influenza vaccine (LAIV)

____________is the most common complication of influenza with ___________ being one of the most frequent etiologic organisms

1) Pneumonia
2) Strep pneumo

What patients who do not hve any contraindication to vaccine should be immunized with the influenza?

All persons >/= 6 months of age

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