PNEUMONIA,,,,,,,,,,,,,,,,,,,,,,,,,,,.pptx

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1. PNEUMONIA

2. A 45-year-old otherwise healthy woman presents with a 3-day history of mild cough, low-grade fever, and fatigue. She has no significant past medical history and no recent travel or exposure to sick contacts.

3. A 62-year-old man with type 2 diabetes and hypertension presents with a 5-day history of high fever, productive cough with green sputum, and shortness of breath. He has been feeling increasingly fatigued.

4. A 62-year-old man with type 2 diabetes and hypertension presents with a 5-day history of high fever, productive cough with green sputum, and shortness of breath. He has been feeling increasingly fatigued.

5. A 60-year-old male with a recent history of stroke and recent intubation presents with new-onset fever and increased respiratory secretions 2 days after intubation.

6. A 75-year-old female with multiple comorbidities and mechanical ventilation for 10 days presents with high fever, severe respiratory distress, and persistent hypoxemia.

7. A 70-year-old woman with diabetes and renal failure presents with severe respiratory distress and hypotension 7 days after a major abdominal surgery. She has developed high fever and increased sputum production with a foul odor.

8. A 55-year-old man who had elective abdominal surgery 3 days ago presents with a new cough, low-grade fever, and mild dyspnea. He was recovering well until the last 24 hours when his symptoms worsened.

9. DIAGNOSIS To evaluate a patient with possible community-acquired pneumonia (CAP), physicians must answer two critical questions: Is this pneumonia? What is the likely pathogen?

10. Clinical Diagnosis Differential Diagnosis : Consider infectious and noninfectious conditions such as acute bronchitis, exacerbations of chronic bronchitis, heart failure, and pulmonary embolism. History and Examination : A detailed history is crucial. Symptoms include cough, sputum production, fever, dyspnea, and a new infiltrate on chest X-ray. Sensitivity and Specificity : Physical exam findings have limited sensitivity (58%) and specificity (67%). Chest radiography is often needed to confirm CAP. Radiographic Findings : Can indicate severity and suggest an etiologic diagnosis (e.g., cavitation in tuberculosis). CT Scans : Useful for suspected loculated effusions or postobstructive pneumonia. Outpatient Management : Clinical and radiologic assessments are often sufficient before treatment begins.

11. Etiologic Diagnosis Challenges : Clinical and radiographic presentations alone usually do not reveal the etiology. In a large study, only 7.6% of cases had an etiologic determination. Importance of Identification : Identifying specific pathogens allows targeted therapy and reduces antibiotic resistance. Public Safety : Identifying pathogens with public health implications, like tuberculosis and influenza, is critical.

12. Diagnostic Techniques Gram’s Stain and Sputum Culture : Ensures specimen suitability. May identify specific pathogens but has variable sensitivity and specificity. Recommended for hospitalized patients, especially with severe CAP or risk of MRSA or P. aeruginosa. Blood Cultures : Low yield (5–14% positive), most commonly identifying S. pneumoniae. Recommended for high-risk patients (e.g., severe CAP, asplenia, MRSA risk). Urinary Antigen Tests : Detect pneumococcal and Legionella antigens. Reliable even after antibiotic initiation. Used in severe cases or when epidemiological factors are present.

13. 4.Polymerase Chain Reaction (PCR) : Amplifies microbial DNA/RNA. Standard for diagnosing viral infections and detecting pathogens like Legionella. Cost-effectiveness remains unclear. 5.Serology : Involves measuring antibody titers. Less favored due to delays and interpretation challenges. 6.Biomarkers (CRP and PCT) : Indicate inflammatory responses but are not definitive for diagnosing bacterial CAP. Best used alongside other diagnostic methods.

14. INDICATIONS FOR ADMISSIONS The decision to hospitalize a patient with community-acquired pneumonia (CAP) is crucial due to the significant cost differences and potential health implications between inpatient and outpatient management.

15. Financial and Health Implications Cost of Care : Hospitalization costs significantly more than outpatient treatment, accounting for the majority of CAP-related expenses. Mortality Risk : Delayed ICU admission is linked to higher mortality rates, making timely decisions critical.

16. Assessment Tools for Hospitalization Pneumonia Severity Index (PSI) Purpose : Identifies patients at low risk of dying. Scoring : Points are assigned based on 20 variables, including age, existing illnesses, and abnormal findings. Risk Classes and Mortality Rates : Class 1: 0.1% Class 2: 0.6% Class 3: 2.8% Class 4: 8.2% Class 5: 29.2% Implications : Patients in classes 1 and 2 can often be managed as outpatients, while class 3 may require observation. PSI is highly effective but complex to calculate.

17. CURB-65 Criteria Components : Confusion, Urea >7 mmol/L, Respiratory rate ≥30/min, Blood pressure ≤90 mmHg systolic or ≤60 mmHg diastolic, Age ≥65 years. Scoring and Recommendations : Score 0: Outpatient treatment (30-day mortality of 1.5%). Score 1 or 2: Consider hospitalization, especially if factors other than age contribute to the score. Score ≥3: High mortality risk (22% overall), ICU admission may be needed. Comparison with PSI : Easier to use but less effective than PSI.

18. Additional Considerations for Hospitalization Clinical Factors : Patients unable to maintain oral intake, with compliance issues, or with O₂ saturation <92% on room air should be hospitalized. Clinical Judgment : Combine prediction rules with clinical judgment to decide the care site.

19. ICU Admission Criteria Direct ICU Admission : Required for patients with septic shock needing vasopressors or acute respiratory failure needing mechanical ventilation. Minor Criteria for ICU : Patients meeting three of the nine minor criteria should be admitted to the ICU or a high-level monitoring unit. Monitoring and Mortality : Higher mortality is observed in patients initially admitted to medical floors who deteriorate compared to those initially monitored in the ICU.

20. Deciding on hospitalization for CAP involves assessing the severity and risk using tools like PSI and CURB-65, alongside clinical judgment. While PSI is more effective, CURB-65 offers a simpler assessment. Ultimately, considerations for patient safety, potential ICU needs, and overall cost impact guide these critical decisions.

21. TREATMENT Antimicrobial resistance is a growing concern in treating community-acquired pneumonia (CAP) as it limits the effectiveness of available antibiotics and poses a significant public health challenge

22. S. pneumoniae Resistance Mechanisms of Resistance: β-lactam Resistance : Resistance is acquired through DNA incorporation, natural transformation, or gene mutation, leading to remodeling of penicillin-binding proteins. Macrolide Resistance : Resistance occurs via ribosomal methylation ( ermB gene) leading to high-level resistance or efflux mechanisms ( mef gene) resulting in low-level resistance. Fluoroquinolone Resistance : Resistance involves mutations in topoisomerases II and IV ( gyrA and parC genes) and possibly efflux pumps.

23. Prevalence and Risk Factors: β-lactam Resistance : Less than 20% of U.S. isolates are resistant to penicillins , and less than 1% are resistant to cephalosporins. Macrolide Resistance : Over 30% of U.S. isolates are resistant, mostly at high levels. Resistance can result in treatment failures if macrolides are used as monotherapy. Fluoroquinolone Resistance : Typically less than 2%. Multidrug Resistance (MDR) : Defined as resistance to three or more classes of antibiotics. 58.9% of penicillin-resistant pneumococcal isolates are also resistant to macrolides.

24. Risk Factors for Resistance : Recent antimicrobial use (within 3 months). Age extremes (<2 or >65 years). Day-care attendance, recent hospitalization, or HIV infection.

25. CA-MRSA (Community-Acquired Methicillin-Resistant S. aureus) Characteristics: Resistance Mechanism : Mediated by the mecA gene, conferring resistance to all β- lactams. SCCmec Types : Hospital strains usually have type II or III; community strains have type IV. Virulence Factors : CA-MRSA often carries genes for toxins like Panton-Valentine leukocidin , contributing to severe disease. Antibiotic Susceptibility : CA-MRSA is generally more susceptible to trimethoprim-sulfamethoxazole, clindamycin, tetracycline, vancomycin, and linezolid compared to hospital-acquired strains.

26. M. pneumoniae Resistance Macrolide Resistance : Increasing due to mutations in domain V of 23S rRNA. Prevalence varies globally: Germany (3%), Japan (30%), China (95%), and the United States (5-13%).

27. Gram-Negative Bacilli Resistance Trends : Escherichia coli : Increasing resistance to fluoroquinolones. Enterobacter species : Typically resistant to cephalosporins, treated with fluoroquinolones or carbapenems. Extended-Spectrum β- Lactamase (ESBL) Producers : Carbapenems are the drugs of choice when infections are suspected or documented.

28. Implications and Management Antibiotic Stewardship : Reducing unnecessary antibiotic use is crucial to prevent resistance. Empirical Therapy : Adjustments may be needed based on local resistance patterns and individual patient risk factors. Patient History : Previous antibiotic use is a key factor in choosing appropriate therapy to avoid resistance issues.

29. Outpatient Management 1. Patients without Comorbidity or Resistance Risk Factors: Recommended Treatment: Amoxicillin alone or doxycycline. Alternative: Macrolide monotherapy only if there is a documented low risk of macrolide resistance (<25%).

30. 2. Patients with Comorbidities or Resistance Risk Factors: Comorbidities: Chronic heart, lung, liver, or kidney disease; diabetes; alcoholism; malignancy; asplenia. Consideration: Use antibiotics from a different class if there has been antibiotic use in the previous 3 months. General Approach: Initiate coverage for both atypical organisms and S. pneumoniae

31. Inpatient Management Nonsevere CAP (No Risk Factors for MRSA or P. aeruginosa): Recommended Treatment: Combination of a β- lactam and a macrolide. Monotherapy with a respiratory fluoroquinolone. Alternative if Contraindications Exist: β- lactam with doxycycline.

32. Severe CAP (No Risk Factors for MRSA or P. aeruginosa): Recommended Treatment: Combination of a β- lactam and a macrolide. Combination of a β- lactam and a respiratory fluoroquinolone.

33. Patients with Risk Factors for MRSA or P. aeruginosa: Risk Factors: Prior isolation of these organisms, recent hospitalization, recent antibiotic treatment, underlying lung disease (e.g., bronchiectasis, severe COPD). Empirical Treatment: MRSA: Linezolid or vancomycin; linezolid preferred due to better lung penetration and inhibition of bacterial exotoxins. Pseudomonas aeruginosa: Use two antipseudomonal agents from different classes if risk factors are present. De-escalation: Consider if cultures are negative and the patient improves clinically.

34. Additional Considerations: Influenza Coinfection: Administer anti-influenza treatment (e.g., oseltamivir) alongside antibacterial therapy. Switching from IV to Oral Therapy: Consider when the patient is hemodynamically stable, improving clinically, and can ingest/absorb medications. Duration of Treatment: Typically 5 days for uncomplicated CAP, longer if complications arise or if the infection involves more virulent pathogens.

35. Aspiration Pneumonia Management Coverage for Anaerobes: Generally unnecessary unless poor dentition, lung abscess, or necrotizing pneumonia is present. Site of Acquisition: Community vs. hospital setting affects treatment approach.

36. Adjunctive Measures Hydration: Ensuring adequate fluid intake to maintain hydration. Oxygen Therapy: Administered for hypoxemia to ensure adequate oxygenation. Vasopressors and Assisted Ventilation: Used when necessary for patients with severe CAP to support blood pressure and respiration. Glucocorticoids: Not routinely recommended but may be used in cases of refractory septic shock.

37. Failure to Improve Patients who do not show improvement by approximately day 3 of treatment should be reevaluated. Key considerations include: Noninfectious Mimics: Conditions such as pulmonary edema, pulmonary embolism, lung carcinoma, radiation and hypersensitivity pneumonitis, and connective tissue diseases can mimic pneumonia. Correct Diagnosis and Treatment: Ensure that CAP is correctly diagnosed and that empirical treatment targets the correct pathogen. Consider the possibility of drug resistance, incorrect drug selection, improper dosing, or administration frequency. Unexpected Pathogens: Consider pathogens such as CA-MRSA, Mycobacterium tuberculosis, or fungal infections if the patient fails to improve. Nosocomial Superinfections: Hospital-acquired infections may complicate recovery. Further Assessment: May involve additional studies like CT scans or bronchoscopy to reassess the patient’s condition.

38. Complications Severe CAP can lead to several complications, including: Respiratory Failure: May require mechanical ventilation. Shock and Multiorgan Failure: Critical conditions needing intensive care. Exacerbation of Comorbid Illnesses: Worsening of existing health conditions. Metastatic Infection: Rare but serious, such as brain abscess or endocarditis, requiring thorough evaluation. Lung Abscess: Can occur with aspiration pneumonia or infections caused by specific pathogens (e.g., CA-MRSA, P. aeruginosa). Complicated Pleural Effusion: Requires drainage if the fluid shows signs of infection or has a low pH, low glucose, and high lactate dehydrogenase. .

39. Follow-Up Resolution of Symptoms: Fever and leukocytosis usually resolve within 2–4 days in healthy patients, but physical findings may persist. Radiographic Abnormalities: Can take 4–12 weeks to resolve, with resolution speed affected by patient age and underlying lung disease. Discharge Considerations: Patients can be discharged once their condition stabilizes. The living situation post-discharge should be considered, especially for elderly patients. Follow-Up Radiography: Recommended for hospitalized patients after 4–6 weeks to ensure resolution. Routine follow-up is unnecessary for nonsmokers managed as outpatients if symptoms resolve in 5–7 days. Recurrence: If symptoms recur, particularly in the same lung segment, underlying neoplasms should be considered

40. Prognosis The prognosis for CAP depends on several factors: Age and Comorbidities: Younger patients without comorbidities tend to recover fully within about 2 weeks. Older patients and those with underlying conditions may take longer. Site of Treatment: The overall mortality rate for outpatients is less than 5%, while for hospitalized patients, it ranges from 12% to 40%, depending on patient category and the timeliness of appropriate antibiotic administration.

41. Vaccination Vaccination is the most effective preventive measure against CAP, particularly for preventing pneumococcal infections and influenza. Following the recommendations of the Advisory Committee on Immunization Practices (ACIP) is crucial for both influenza and pneumococcal vaccines.

42. Pneumococcal Vaccines Two types of pneumococcal vaccines are available Pneumococcal Polysaccharide Vaccine (PPSV23): Contains capsular material from 23 pneumococcal serotypes. Recommended for adults over 65 and for younger individuals with certain health conditions. Pneumococcal Conjugate Vaccine (PCV13): Contains capsular polysaccharide from 13 common pneumococcal serotypes affecting children, linked to an immunogenic protein. Produces T-cell–dependent antigens, resulting in long-term immunologic memory. Recommended for children, the elderly, and younger immunocompromised patients. Has led to a decrease in antimicrobial-resistant pneumococci and invasive pneumococcal disease in both children and adults. A potential concern is the replacement of vaccine serotypes with nonvaccine serotypes, such as serotypes 19A and 35B.

43. Influenza Vaccine Available in inactivated or recombinant forms. Recommended annually for most individuals, especially those at high risk of influenza complications, such as the elderly, young children, and those with chronic health conditions. During an influenza outbreak, unvaccinated high-risk individuals should receive the vaccine immediately. Chemoprophylaxis with antiviral medications such as oseltamivir or zanamivir is recommended for 2 weeks following vaccination to provide protection until antibody levels are sufficient.

44. Lifestyle Modifications Smoking Cessation: Smokers are at increased risk for pneumococcal infections. Smoking cessation is strongly encouraged to reduce the risk of CAP, even among those without obstructive lung disease.

45. ventilator-associated pneumonia (VAP)

46. Challenges in VAP Diagnosis Tracheal Colonization: Patients with endotracheal tubes frequently have tracheal colonization with pathogenic bacteria, which can be mistaken for pneumonia. Alternative Causes of Infiltrates: Multiple conditions can cause radiographic infiltrates in mechanically ventilated patients, including pulmonary edema, contusion, alveolar hemorrhage, hypersensitivity pneumonitis, acute respiratory distress syndrome (ARDS), and pulmonary infarction. Other Sources of Fever: Fever and leukocytosis in critically ill patients may stem from causes other than VAP, such as: Antibiotic-associated diarrhea Central line–associated infection Sinusitis Urinary tract infection Pancreatitis Drug fever Many conditions mimicking pneumonia do not require antibiotic treatment, require different antibiotics (e.g., for fungal or viral pneumonia), or need additional interventions like surgical drainage or catheter removal.

47. Diagnostic Approaches . Quantitative-Culture Approach This method uses quantitative cultures of deep respiratory tract samples to differentiate between colonization and true infection. The specificity of the results increases the further the sample is taken from the respiratory tree, resulting in a lower growth threshold to diagnose pneumonia. Endotracheal Aspirates: Proximal samples with a diagnostic threshold of 10^6 cfu / mL. Protected Specimen Brush Method: Distal samples with a threshold of 10^3 cfu / mL. Additional Tests: Gram staining Differential cell counts Staining for intracellular organisms Detection of elevated local protein levels in response to infection .

48. Advantages: Reduces antibiotic use compared to clinical diagnosis. Antibiotic decisions can be based on culture results, with withholding of antibiotics until necessary unless the patient is critically ill. Limitations: Recent antibiotic use can lead to false-negative results. Colony counts can fall below diagnostic thresholds if samples are collected early in infection or delayed until after an effective host response

49. Clinical Approach While clinical diagnosis lacks specificity, the approach can be enhanced by integrating microbiologic and laboratory data: Tracheal Aspirates: Although they yield more potential pathogens than quantitative cultures, the causative pathogen is almost always present. The absence of bacteria in Gram-stained aspirates makes pneumonia an unlikely cause. Benefits: Prevents inappropriate antibiotic overtreatment. Absence of an MDR pathogen in cultures can lead to de-escalation of empirical therapy. New molecular diagnostic methods can rule out suspected MDR pathogens.

50. Antibiotic Management in Ventilator-Associated Pneumonia (VAP) Importance of Timely and Appropriate Therapy Delayed initiation of appropriate empirical antibiotic therapy in VAP is associated with higher mortality rates. The choice of antibiotics should be guided by the resistance patterns of the likely pathogens and the patient’s risk factors for multidrug-resistant (MDR) infections.

51. Antibiotic Resistance VAP often involves MDR pathogens due to: Selection Pressure: Frequent use of β- lactam drugs, especially cephalosporins, promotes resistance in pathogens like MRSA and ESBL-producing Enterobacteriaceae. Intrinsic Resistance: Pathogens such as Pseudomonas aeruginosa and Acinetobacter species are intrinsically resistant to many antibiotics. Emergence of Resistance: Pseudomonas can develop resistance during treatment, and pathogens like Acinetobacter and Stenotrophomonas maltophilia show intrinsic resistance to many regimens.

52. Empirical Therapy Initial Empirical Therapy: Should be started after obtaining diagnostic specimens. The selection depends on: Risk Factors for MDR Pathogens: Patients with risk factors require more aggressive therapy. Local Resistance Patterns: Knowledge of local antibiograms and prior antibiotic exposure is crucial.

53. Options for Empirical Therapy: Patients Without MDR Risk Factors: Often treated with a single agent. This approach has shown lower mortality compared to combination therapy in low-risk patients. Patients With MDR Risk Factors and High Mortality Risk: Typically treated with a combination of three antibiotics: Two agents targeting Pseudomonas aeruginosa . One agent targeting MRSA. Important Considerations: A single agent may suffice if it covers the majority of gram-negative pathogens in the ICU. β-Lactams: Provide broad coverage but may still be inappropriate in up to 10–15% of cases. Polymyxins: Added in areas with high carbapenem resistance. Emerging Agents: Include ceftazidime–avibactam, ceftolozane –tazobactam, imipenem– relebactam , and plazomicin for resistant strains.

54. Specific Treatment De-Escalation: Once the pathogen is identified, broad-spectrum therapy can often be narrowed to a single agent. Therapy duration is usually 7–8 days but may extend if initial therapy was inadequate or if resistant organisms are involved. Combination Therapy for Pseudomonas: Generally not recommended beyond initial therapy due to lack of survival benefit in most cases, though it may be considered in bacteremic infections with septic shock.

55. Failure to Improve Common Issues: Resistance: MRSA and Pseudomonas VAP often show high failure rates. Inappropriate Therapy: Results from poor initial choices or emergence of resistance. Recurrent Infection: May occur due to biofilm on endotracheal tubes or new strains of the pathogen.

56. Potential Solutions: Optimized β-Lactam Dosing: Using prolonged or continuous infusion may improve outcomes. Alternate Antibiotics: Linezolid can be more effective than vancomycin, especially in high-MIC isolates. Evaluation: Serial Cultures: Useful for understanding the microbiological response. Biomarkers: Such as procalcitonin (PCT), may have limited utility.

57. Complications of Ventilator-Associated Pneumonia (VAP) 1. Prolonged Mechanical Ventilation: Impact: VAP often leads to an extended need for mechanical ventilation, which increases the duration of ICU and hospital stays. Justification: The additional week of mechanical ventilation due to VAP emphasizes the importance of preventive measures. 2. Necrotizing Pneumonia: Causes: Rare, but can be due to Pseudomonas aeruginosa or Staphylococcus aureus . Consequences: Can result in significant pulmonary hemorrhage, bronchiectasis, and parenchymal scarring leading to recurrent pneumonia.

58. 3. Long-Term Complications: Oxygen Therapy: Patients may require long-term oxygen therapy. Catabolic State: Particularly concerning for nutritionally at-risk patients. Rehabilitation Needs: Extended rehabilitation may be necessary. Functional Decline in the Elderly: May result in an inability to return to independent living and the need for nursing home placement.

59. Follow-Up Clinical Improvement: Timing: Usually observed within 48–72 hours of starting antimicrobial treatment. Indicators: Improvement in clinical symptoms and oxygenation. Chest radiography may initially worsen, making it a less reliable indicator of response. Prognosis Mortality Rates: Crude Mortality: Can be as high as 50–70%. Attributable Mortality: Often lower, with estimates around 25% in some studies. Varies based on patient population, ICU type, and pathogen involved. Pathogen Influence: MDR pathogens are associated with higher attributable mortality. For example, Stenotrophomonas maltophilia often indicates a severely compromised immune system.

60. Prevention Strategies 1. Minimizing Intubation: Avoidance: Preventing or minimizing the duration of intubation is crucial. Noninvasive Ventilation: Preferred to avoid complications associated with endotracheal tubes. 2. Sedation and Weaning: Daily Sedation Interruption: Helps reduce the need for prolonged ventilation. Weaning Protocols: Effective in preventing VAP. 3. Risks of Extubation : Early Extubation : May result in reintubation and increased risk of aspiration. Sedation Balance: Insufficient sedation can lead to self- extubation , increasing VAP risk.

61. 4. Antibiotic Use: Short-Course Prophylaxis: Reduces risk of early-onset VAP but prolonged use increases risk of MDR VAP. Antibiotic Stewardship: Avoid prolonged courses to reduce the risk of MDR pathogens. 5. Preventing Microaspiration : Head of Bed Elevation: Keeping the head of the bed elevated (at least 30°, ideally 45°) can reduce microaspiration . Modified Endotracheal Tubes: Tubes that allow for removal of secretions pooled above the cuff can help prevent aspiration.

62. 6. Transporting Patients: Risk Consideration: Transporting patients outside the ICU for diagnostic tests should be carefully evaluated due to increased VAP risk. 7. Gastric pH and Bowel Flora: Elevated Gastric pH: The role in VAP pathogenesis is questionable, though avoidance of agents that raise gastric pH may be relevant in specific populations (e.g., liver transplant recipients). 8. Infection Control: Monitoring Outbreaks: Investigate potential breakdowns in infection control measures, such as reusable equipment contamination. Education: Emphasize hand hygiene and infection control practices to prevent cross-infection and outbreaks.

63. Hospital-Acquired Pneumonia (HAP) Comparison with Ventilator-Associated Pneumonia (VAP): Pathogens: HAP in non-intubated patients generally has a higher frequency of non-MDR pathogens compared to VAP. Host Immunity: Non-intubated patients typically have better underlying host immunity. Antibiotic Therapy: Due to the lower frequency of MDR pathogens, monotherapy is more commonly effective for HAP than VAP.

64. Pathogens: Anaerobes: May be more common in non-intubated HAP patients due to macroaspiration and lower oxygen tensions in the lower respiratory tract. However, they usually contribute to polymicrobial infections. Most recommended antibiotics are active against anaerobes, so specific targeting may not be necessary.

65. Diagnosis Challenges: Sample Collection: Obtaining appropriate lower respiratory tract samples for culture is more challenging in non-intubated patients. Coughing Ability: Many patients with HAP have underlying conditions that impair their ability to cough effectively. Blood Cultures: Positive blood cultures are rare (<15% of cases), making it difficult to base antibiotic modifications on culture data.

66. Management and Outcomes: De-escalation: Less likely in HAP due to limited culture data. Mortality and Risk: Better host defenses in non-ICU patients lead to lower mortality rates compared to VAP and ventilated HAP. The risk of antibiotic failure is also lower in HAP

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