Hospital Acquired Pneumonia

This Presentation gives you the basic idea on Different types of Pneumonia, treatment approach and Case studies

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Hospital Acquired
Pneumonia(HAP)

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Respiratory System
• Primary function is to obtain
O2 for use by body's cells &
eliminate Co2 that cells produce
•Pathway of air: Nasal cavities
(or oral cavity) > pharynx >
trachea > primary bronchi (right
& left) > secondary bronchi >
tertiary bronchi > bronchioles >
alveoli (site of gas exchange)

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Definition of HAP
•HAP is defined as pneumonia that occurs 48 hours or
more after admission


•This infection was neither present nor incubating at
the time of hospitalization
After 48 hrs
in hospital

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Definitions of VAP and HCAP
•Ventilator-associated pneumonia (VAP) refers to the development of parenchymal lung infection after
the patient has undergone intubation and received mechanical ventilation after at least 48 hours.

•Health-care-associated pneumonia (HCAP) refers to pneumonia that develops inside or outside the
hospital in the presence of risk factors for multi-drug-resistant pathogens because of prior contact with
health-care environment

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Incidences

•2nd most common nosocomial infection
•Rate 5-15 cases/ 1000 hospital admission
•Increases hospital stay by 7-9 days / patient
•Excess cost of more than $ 40,000 / patient
•Mortality rate is seriously high 30- 50 %

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Time of onset
•Early vs. Late
•For HAP-early onset:
•Diagnosed 2-5 day after hospitalization
•For HAP-late onset:
•Diagnosed >5 days after hospitalization

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Risk factors for MDR pathogens in HAP

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Source of pathogens
Contaminated hands
and Apparels of
health
Care workers
Oropharyn
geal

colonizatio
n
Gastric
coloniza
tion
European Journal of Internal Medicine 21 (2010) 360–368

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Microbiology of HAP
Common pathogens associated with HAP

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Pathogenesis of nosocomial Pneumoniae
•For any infection interplay of three factors
•Impaired host defense
•Access of bacteria in sufficient numbers to the lower respiratory tract
•Virulence of the organism
•The organism may gain access into the lungs by one of several routes;
•Micro aspiration of oropharyngeal secretions
•Aspiration of gastric contents, inhalation, hematogenous spread, direct
inoculation and exogenous penetration (e.g. pleural space).
•Of these, micro-aspiration is the most common.

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Pathogenesis of nosocomial bacterial Pneumoniae
Host
factors
Medicatio
ns
Respiratory
therapy
equipment
Surgery

Invassive
devices
Gastric
colonization
Aspiration
Numbers of bacteria virulence
Bacteremia
Lung Defenses
Mechanical
cellular/humoral
Pneumonia
Oropharyngeal
colonization
Translocation

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Infected lung
Pleural effusion

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Pathogenesis of infective Pneumonia

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Diagnosis
•The guidelines address two separate diagnostic strategies for HAP, VAP, and HCAP

•Clinical strategy
•And
•Bacteriologic strategy

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Clinical strategy
•Clinical
•Fever (>380C)
•Cough with purulent sputum
•Radiographic
•New or progressive
infiltrates on Chest X-ray
•Laboratorial
•Leukocytosis or leukopenia
(Increase or decrease WBC)

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Microbiological Diagnosis of HAP
•Suggestive Gram stain and positive
cultures of
•Blood culture
•Samples of lower respiratory tract
secretion should be obtained
including:
•Endotracheal aspirate
•BAL, or Protected specimen brush
sample
•If there a complicating empyema, a
pleural aspirate should be obtained
Bronchoalveolar lavage with
bronchoscopy
Bronchial Aspirate
Sampling

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Diagnostic strategy
HAP is suspected: The presence of a
new or progressive radiographic
infiltrate plus at least two of three
clinical features (fever >38oC,
leukocytosis or leukopenia & purulent
secretions)
Lower respiratory tract sample for
microscopy & culture: from all
patients, ideally before antibiotic
started .
Semi-quantitative or quantitative: In
quantitative cultures the diagnostic
threshold is ETA 106 cfu/ml, BAL 104
or 105 cfu/ml, PSB 103 cfu/ml.

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Management of HAP
Day 1
Day 2 and
3

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Empirical Antibiotic therapy in HAP
•Once the clinical decision has been made to initiate therapy, the overall
approach to therapy is summarized in the following algorithm

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Initial empiric therapy for HAP/VAP in patients with no known risk
factors for MDR pathogens, early onset and any disease severity

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Initial empiric therapy for HAP/VAP in patients with late-onset disease or
risk factors for MDR pathogens and all disease severity

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Initial intravenous, adult doses of antibiotics for empiric therapy of HAP/VAP in
patients with late-onset disease or risk factors for MDR pathogens

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Duration of Therapy


•Efforts should be made to shorten the duration of therapy from the traditional 14 to 21 days to periods as
short as 7 to 8 days, provided that the etiologic pathogen is not P. aeruginosa, and that the patient has a
good clinical response with resolution of clinical features of Infection.

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Case presentation
Case history
a 64-year-old male who presented for severe abdominal pain,
fever, and dehydration for approximately the last 24 hours

Pat history: Insulin-dependent diabetic, hypertension
Social history: Moderate alcoholic and smoker

Physical examination: BP 90/60
Heart rate 135
Temperature 40°C
Respiratory rate30
Had cool, clammy skin
Rectal heme positive
Lab: WBC 16,000, Hematocrit 32

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Case presentation (continued...)
•Resuscitation with fluids and he was started on empiric
Piperacillin-Tazobactam and levofloxacin.
•An abdominal CT scan revealed Appendicitis, operated accordingly
•Postoperative Treatment Day1
• He was extubated the morning after surgery and recovered well.
•Postoperative day 2
• He was afebrile by the second postoperative day and his white blood
count gradually decreased

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Case presentation (continued...)
•Postoperative day 3
•Transferred to surgical ward
•Same Ab therapy had been continued
•On postoperative day 8
•Started on oral feedings
•On postoperative day 10
•Developed fever (39.5°C) and once again his WBC increased to 12,000

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Case presentation (continued...)
•Diagnostic evaluation
•Removal of his Central Venous catheter (CVC)
•Culturing of the catheter tip, sputum, blood
•A new CVC was inserted at a new site
•A chest x-ray at that time revealed a new right mid-lung
infiltrate

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Case presentation (continued...)
•Base on clinical and laboratory parameters Diagnosed as HAP
•Sputum culture demonstrated K.pneumoniae sensitive to ELORES and colistin
•Patient Ab therapy switched to ELORES 3g B.I.D
•After 6 days of ELORES therapy
•Patient was afebrile
•Normal WBC count
•Chest X-ray was normal
•He was subsequently discharged from hospital

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Question & Answer hour
NO
Hospitalized
patient
No further
Investigatio
ns
& observe
Yes
If
Abnor
mal ?
Observe &
investigate
for other
sources
No
Y
es
What doctor do ?
Clinical
features
of HAP?

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Question & Answer hour (Continue...)
Option B:
Emperic
treatment
+
Qualitative
culture
Adjust treatment
According to
Culture results or
Clinical response
Option A:
Quantitative culture
Treat based on results
Of diagnostic testing
If clinically
unstable
Yes
What are
Cultures samples
do suggest here?

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THANK YOU

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Answers
NO
Hospitalized
patient
Clinical features
Suggest
Infection?
No further
Investigatio
ns
& observe
Yes
Order/review
recent CXR
Abno
rmal ?
Observe &
investigate
for other
sources
No
Y
es

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Nonbronchoscopi
c:

EA ,BAL ,PSB
Option B:
Emperic
treatment
+
Qualitative
culture
Adjust treatment
According to
Culture results or
Clinical response
Option A:
Quantitative culture
Bronchoscopi
c:

BAL, PSB,
PBAL
Treat based on results
Of diagnostic testing
If clinically
unstable
Yes