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Hospital Acquired Pneumonia

Mohan Gamesh

Definition
Refers to a new episode of pneumonia occurring at least 2 days (48 hours) after admission to hospital The term includes
post-operative cases certain forms of aspiration pneumonia pneumonia or bronchopneumonia developing in patients chronic lung disease general debility those receiving assisted ventilation

Early onset
Occuring <5days after hospital admission Commonly associated with Antibiotic-sensitive bacteria: - H. influenzae, oxacillin-sensitive S. aureus, and S. pneumoniae No risk factors for infection due to potentially antibiotic-resistant bacteria: - Antibiotic treatment or prior health care facility exposure
American Thoracic Society

Late onset

Occuring 5 days after hospital admission


Usually antibiotic-resistant bacteria: - MRSA, P. aeruginosa, Acinetobacter spp., Enterobacter spp.

American Thoracic Society

Important distinction btw hospital- & community acquired pneumonia


Difference in the spectrum of pathogenic organisms Majority of hospital-acquired infections caused by Gram-negative bacteria. Include: - Staph. aureus (including multidrug-resistantMRSA-forms) - Escherichia - Pseudomonas - Klebsiella species

Factors predisposing HAP


Reduced host defences against bacteria
immune defences (e.g. corticosteroid treatment, diabetes, malignancy) cough reflex (e.g. post-operative)

Disordered mucociliary clearance (e.g. anaesthetic agents)


Bulbar or vocal cord palsy

Aspiration of nasopharyngeal / gastric secretions


Immobility or reduced conscious level Vomiting, dysphagia, achalasia or severe reflux Nasogastric intubation

Bacteria introduced into lower respiratory tract


Endotracheal intubation/tracheostomy Infected ventilators/nebulisers/bronchoscopes Dental or sinus infection

Bacteraemia
Abdominal sepsis Intravenous cannula infection Infected emboli

Clinical features and investigation of patients with hospital-acquired pneumonia are very similar to CAP
Clinical Features include: Shortness of breath Cough + sputum Fever Chills + Rigors Pleuritic Chest pain Nausea and vomiting Others: Lost of appetite, Headache, Fatigue, myalgias, arthalgias, anorexia

Physical examination shows: - Respiratory distress - Crepitations or breath sounds


Tests performed may include: - Chest x-ray - Arterial blood gases - Complete blood count - Blood cultures - Sputum culture - Sputum gram stain

Management
Adequate gram ve coverage is usually obtained with:
3rd generation cephalosporin (eg. Cefotaxime) + an aminoglycoside (eg. Gentamicin) or Meropenem or A monocyclic -lactam (eg. Aztreonam) + flucloxacillin

Aspiration pneumonia can be treated with coamoxiclav 1.2g 8 hourly + Metronidazole 500mg 8 hrly. Physiotherapy important in immobile & elderly.
Adequate O2 therapy, fluid support and monitoring

Initial empiric therapy: ATS approach

References:
American Thoracic Society Documents Guidelines for the Management of Adults with Hospital-acquired, Ventilatorassociated, and Healthcare-associated Pneumonia

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