Transcript hospitalpneumonia

Hospital Acquired Pneumonia
Definitions
• Community acquired pneumonia (CAP)
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Infection of the lung parenchyma in a person who is not hospitalized or living in a long-term care
facility for ≥ 2 weeks
• Hospital-acquired pneumonia (HAP)
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Occurs 48 hours or more after admission, which was not incubating at the time of admission
• Healthcare-associated pneumonia (HCAP) is defined as
pneumonia that occurs in a non-hospitalized patient with
extensive healthcare contact, as defined by one or more of
the following:
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Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days.
Residence in a nursing home or other long-term care facility
Hospitalization in an acute care hospital for two or more days within the prior 90 days
Attendance at a hemodialysis clinic within the prior 30 days
• Ventilator-associated pneumonia (VAP)
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Arises more than 48-72 hours after endotracheal intubation
Initial Evaluation of Suspected
Pneumonia
• Common clinical features
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Cough
Fever/Chills
Pleuritic chest pain
Dyspnea
Sputum production
Some may have GI symptoms including nausea, vomiting and
diarrhea
• Physical Exam
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Fever
Respiratory Rate >24
Tachycardia
Chest examination may reveal audible rales
Initial Evaluation of Suspected
Pneumonia
• A chest radiograph should be obtained in patients with
suspected pneumonia when possible; a demonstrable
infiltrate by chest radiograph or other imaging technique is
required for the diagnosis of pneumonia, according to the
2007 consensus guidelines from the Infectious Diseases
Society of America and the American Thoracic Society
(IDSA/ATS)
• The radiographic appearance of Pneumonia may include
lobar consolidation, interstitial infiltrates, and/or cavitation.
Initial Evaluation of Suspected
Pneumonia
• The 2007 IDSA/ATS consensus guidelines
recommend for diagnostic testing:
– For outpatients with CAP routine diagnostic tests
are optional.
– Hospitalized patients should have CBC w/ diff,
blood cultures and sputum Gram stain and culture
– Patients with severe CAP requiring ICU admission
should have blood cultures, urinary antigen tests,
and sputum culture (either expectorated or
endotracheal aspirate)
Hospital Admission
• There are a Severity-of-illness scores that can help guide
whether to admit or not but should not be used over
clinical judgment of the patient and situation.
• CURB-65 criteria (>2, more-intensive treatment)
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Confusion
Urea 7 mmol/L (20 mg/dL)
Increased respiratory rate >30
low blood pressure (SBP <90 or DBP <60)
• Pneumonia Severity Index (PSI)
– uses demographics, the coexistence of co-morbid
illnesses findings on physical examination, vital signs
and essential laboratory findings
HAP/HCAP/VAP Pathogens
American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of
adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J
Respir Crit Care Med 2005; 171:388.
HAP/HCAP/VAP Pathogens
• No known risk factors for multidrug-resistant pathogens, early
onset, and any disease severity
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Streptococcus pneumoniae
MSSA
Haemophilus influenzae
Klebsiella pneumoniae
Enterobacter
Escherichia coli
Acinetobacter
• Has risk factors for Multidrug resistant pathogens
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ESBL
Legionella pneumophila
MRSA
P aeruginosa *** consider especially with VAP
HAP/HCAP/VAP Treatment
American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospitalacquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171:388.
HAP/HCAP/VAP Treatment
American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with
hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;
171:388.
Failure to Improve
• If patient does not improve on broad
spectrum antibiotics may need to consider
possibilities including Fungal Pneumonias, TB,
PJP, Viral Pneumonias or even ARDs.
References
• Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases
Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired
pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27.
• American Thoracic Society, Infectious Diseases Society of
America. Guidelines for the management of adults with hospitalacquired, ventilator-associated, and healthcare-associated
pneumonia. Am J Respir Crit Care Med 2005; 171:388.
• Schuetz P, Christ-Crain M, Thomann R, et al. Effect of
procalcitonin-based guidelines vs standard guidelines on
antibiotic use in lower respiratory tract infections: the ProHOSP
randomized controlled trial. JAMA 2009; 302:1059.