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Definition

Pneumonia developing more than 2-3 days after admission to hospital.

Epidemiology
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0.5-5% of hospital patients higher incidence in certain groups, eg postoperative patients and patients in !".

Pathogenesis
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#hought to result from micro-aspiration of $acteria coloni%ing the upper respiratory tract and stomach. &icroaspiration has $een sho'n to occur in (5% of humans 'hen asleep and the upper air'ay of )5% of critically ill patients is coloni%ed $y enteric gram -ve $acilli. *ther routes of infection include+
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macro-aspiration of gastric contents inhaled aerosols haematogenous spread spread from pleural space direct innoculation from !" personnel translocation from gut follo'ed $y haematogenous spread ,unproven-

.is/ factors

Patient related factors
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0evere illness !oma &alnutrition Prolonged hospitali%ation 1ypotension &eta$olic acidosis 0mo/ing !ertain comor$id illnesses
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!20 dysfunction !*PD D& alcoholism uraemia respiratory failure

0ome studies suggest the incidence increased 'hile others suggest incidence is decreased increase the proportion of cases due to Pseudomonas and 4cineto$acter • • 12 antagonists and antacids immunosuppression Enteral feeding • • • • • increased ris/ of reflu5 overgro'th of 6ram negative $acilli in stomach impaired lo'er oesophageal tone due to 26 tu$e early enteral feeding thought to $e $eneficial even though it may increase ris/ of nosocomial pneumonia higher indicence of nosocomial pneumonia amongst patients fed in a supine position compared 'ith semi-recum$ent Impaired defences • • drugs surgery o o prolonged or complicated upper a$dominal or thoracic • • E## tracheal suctioning o not clear 'hether use of closed suctioning systems alters incidence of ventilator associated pneumonia Respiratory equipment .Infection control related factors • • poor hand 'ashing contaminated e3uipment Intervention related factors Drugs • • sedatives anti$iotics o o effect of prior anti$iotics on development of nosocomial pneumonia unclear.

aureus. !" to !" and at different times in the same !" . aspiration. &ay $e diagnosed on the $asis of+ o o ne' infiltrate or change in an infiltrate on !<.• heated 'ater humidifier may $e associated 'ith higher incidence of 74P compared to heat and moisture e5changer 4etiology • • • • • • 6ram -ve $acilli have $een predominant causes $ut recent data suggest that gram 8ve $acteria . *f particular importance is that Pseudomonas aeruginosa and 4cineto$acter are common in late onset . core temperature 3@.3A! or greater sputum gram stain 'ith scores of 92 out of ( of polymorphonuclear leucocytes and $acteria • • clinical criteria have very poor specificity o semi-3uantitive culture of sputum increases specificity and may $e helpful in diagnosing pneumonia $ut may not $e sufficiently specific in identifying the responsi$le organisms identification of the organism responsi$le difficult due to the high incidence of coloni%ation of the oropharyn5 $y gram negative $acteria o B30-(0% of non-critically ill patients $ecome coloni%ed 'ithin (@ hours 'hile the figure for mori$und and chronically ill patients is a$out )0-)5% . pulmonary em$olus.egionella should $e considered in patients receiving steroids 'ho are not intu$ated at the time they develop pneumonia Pneumonia caused $y multiple organisms common nfection $y multi-resistant organisms common Diagnosis • may $e difficult+ the clinical features of pneumonia are nonspecific and many non-infectious conditions .can cause infiltrates on a chest <-ray. and gro'th of pathogenic organisms from sputum plus one of+    =:! count 9>2 5 >05?.particularly 0. congestive heart failure and cancer.nosocomial pneumonia $ut unusual in early onset 2: causative organisms differ from hospital to hospital.are $ecoming more common #ime of onset and certain ris/ factors associated 'ith a higher incidence of certain organisms.93-5 days after admission to hospital.eg atelectasis.

needs to 'eighed against cost of unnecessary anti$iotic treatment for patients 'ho do not actually have pneumonia-. availa$le to patients 'ith small diameter endotracheal tu$es and of having less effect on gas e5change. 7entilator associated pneumonia • • su$set of hospital ac3uired pneumonia.B)5% $lind techni3ues have the advantage of $eing less invasive.• o $lood cultures are only positive in a$out C% of cases of nosocomial pneumonia.$lind. availa$le to non-$ronchoscopists. 4lthough these data are used to support the use of invasive sampling it may have $een the 3uantitative culture that 'as the /ey difference o although $ronchoscopic techni3ues are pro$a$ly most accurate non-$ronchoscopic . for e5ample. $rushing and $ronchoalveolar lavage.protected specimen $rushing and mini$ronchoalveolar lavage associated 'ith good sensitivity and accepta$le specificity . much higher incidence of Pseudomonas and 4cineto$acter nvestigations • • 0imilar to those re3uired for community ac3uired pneumonia *rganisms causing pneumonia are usually present in the tracheal aspirate as 'ell+ thus. o techni3ues include aspiration. invasive techni3ues for collection of distal air'ay secretions associated 'ith higher specificity $ut considera$ly greater cost . !an $e performed $lindly via an endotracheal tu$e or under direct vision using a $ronchoscope o false negative results due to+  sampling at an early stage of infection 'hen $acterial load lo'  sampling from an unaffected segment of lung  incorrect processing  sampling after starting antimicro$ial o recent randomi%ed controlled trial demonstrated an improved outcome amongst patients investigated $y invasive $ronchoscopic sampling and 3uantitative micro$iology compared to those investigated 'ith conventional sputum sampling and conventional micro$iology. 2egative . if Pseudomonas is not present in the tracheal aspirate it pro$a$ly is not responsi$le for the pneumonia $ut if it is present it cannot $e concluded that it is the cause.

although not all studies have sho'n a difference in survival amongst those 'ho 'ere treated 'ith ade3uate anti$iotic therapy compared 'ith inade3uate anti$iotic therapy nitial selection of antimicro$ials should $e made on the $asis of+ o ris/ factors . of limited value for assessing response .ittle data to guide duration of therapy o 4#0 recommends >(-2> days for follo'ing. aeruginosa or 4cineto$acter spp  multilo$ar involvement  malnutrition  severe de$ilitation  cavitation  necroti%ing 62: pneumonia o Disadvantages of prolonged course of anti$iotics+  selection of resistant $acteria  increased ris/ of to5icity  cost . :acteraemia is associated 'ith a 'orse prognosis.if :4.?P0: sample .?P0: performed#he results of micro$iological investigations are used to narro' antimicro$ial cover later. 0ome organisms are virtually al'ays pathogens 'hen recovered from respiratory secretions . infiltrates.ta$le 5o results of surveillance samples from the patient o local $acterial flora and resistance patterns o 6ram stain of :4. predominantly $ecause of ris/ of relapse+  P.• • tracheal aspirate suggests that pneumonia is not the cause of !<.needs to $e $alance against cost of relapse- • • • • Response to therapy • • !linical improvement usually not apparent for (@-)2 h and therapy should not $e changed in this time !<. n 50% of patients 'ith severe hospital ac3uired pneumonia and positive $lood cultures there is another source of sepsis. 4n outline of management $ased on an invasive approach is given in figure > . &anagement • Early treatment 'ith antimicro$ials that cover all li/ely pathogens is thought to result in a reduction in mor$idity and mortality.ta$le 2:lood cultures identify aetiological agent in @-20% of patients.

unli/ely to prevent gram negative pneumoniaselective decontamination of the digestive tract.apidly deteriorating !<.asp.epo. . 4spiration of su$glottic secretions 'hich pool a$ove the cuff of the endotracheal tu$e is thought to decrease aspiration of oropharyngeal organisms and has $een sho'n in to $e associated 'ith a lo'er incidence of ventilator associated pneumonia.cdc.!D!.  .guidelines for prevention of nosocomial pneumonia can $e found at http+??aepo-5dv'''. pattern.?P0:  !#?"0+ D empyema.gov?'onder?prevguid?m00(53C5?m00(53C5. ne' cavitation or significant ne' pleural effusion should raise concern f patient fails to respond consider+ o s it pneumoniaD o 1ost factors . a$scess  *ther source of infection  *pen lung $iopsy  0teroids Prevention Regimens of proven value • • • hand 'ashing+ the most effective. Widely used and probably effective • • • • • 2utritional support !areful handling of ventilator tu$ing and associated e3uipment 0u$glottic drainage of secretions.eg immunosuppressed. deterioration is common !<. de$ilitatedo :acterial factors . inade3uate dose  . 950% increase in si%e of infiltrate in (@h. improvement often lags $ehind clinical response .ateral rotational $ed therapy !losed suction systems #he !enters for Disease !ontrol .evie' anti$iotics.eg virulent organismo #herapeutic factors .epeat cultures  nvasive micro$iology+ :4.eg 'rong drug. isolation . Prognosis .• • • • nitial !<.

aic.• • mortality is higher in patients 'ith ventilator associated pneumonia than those 'ithout o increased mortality may $e due to association of 74P 'ith increased severity of illness rather than due to 74P itself ho'ever it is li/ely that 74P does have a direct effect on outcome mortality higher for 74P due to aero$ic gram -ve $acilli compared to 74P due to gram 8ves . http+??'''.'hen organisms are fully suscepti$le to anti$iotics-.edu.htm .h/?'e$@?2osocomial%20pneumonia.cuh/.