NEUMONIA NOSOCOMIAL

Mg. Bernardo C. DAMASO MATA

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Nosocomial Pneumonia,
Hospital-Acquired Pneumonia,
Ventilator-Associated Pneumonia, and
Health CareAssociated Pneumonia
Neumonia intrahospitalaria

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Essentials of diagnosis
Hospital-acquired pneumonia (HAP) occurs >48 hours
after admission to the hospital or other health care facility
and excludes any infection present at the time of admission.
Health careassociated pneumonia (HCAP) occurs in
community members whose extensive contact with
healthcare has changed their risk for virulent and drug
resistant organisms.
At least two of the following: fever, leukocytosis, purulent
sputum.
New or progressive parenchymal opacity on chest
radiograph.
Especially common in patients requiring intensive care or
mechanical ventilation.

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Hospitalized patients carry different flora with different

resistance patterns than healthy patients in the community,
and their health status may place them at higher risk for
more severe infection. The diagnostic approach and
antibiotic treatment of patients with hospital-acquired
pneumonia (HAP) is, therefore, different from patients with
CAP.

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Similarly, management of patients in whom pneumonia

develops following endotracheal intubation and mechanical
ventilation (ventilator-associated pneumonia or VAP) should
address issues specific to this group of patients.

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Some community members have extensive contact with the

healthcare system and carry flora that more closely
resemble hospitalized patients than healthy community
residents. When pneumonia develops in these persons, the
infection is referred to as health careassociated
pneumonia (HCAP).
Initial management and antibiotic therapy should be
targeted to the common flora and specific risk factors for
severe disease.

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Considered together, these nosocomial pneumonias

(HAP/VAP/HCAP) represent an important cause of morbidity
and mortality despite widespread use of preventive
measures, advances in diagnostic testing, and potent new
antimicrobial agents.
HAP is the second most common cause of infection among
hospital inpatients and is the leading cause of death due to
infection with mortality rates ranging from 20% to 50%.

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While a minority of cases occurs in ICU patients, the

highest-risk patients are those in ICUs or who are being
mechanically ventilated; these patients also experience
higher morbidity and mortality from HAP. As management
of more chronic illnesses shifts to the outpatient setting,
more cases of HCAP are caused by unusual organisms, and
there is a high frequency of drug resistance.
Definitive identification of the infectious cause of a lower
respiratory infection is rarely available on presentation,
thus, rather than pathogen-directed antibiotic treatment,
the choice of empiric therapy is informed by epidemiologic
and patient data.

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Definition & Pathogenesis
HAP develops more than 48 hours after admission to the
hospital and VAP develops in a mechanically ventilated
patient more than 48 hours after endotracheal intubation.
HCAP is defined as pneumonia that occurs in a
nonhospitalized patient with extensive healthcare contact,
and the risk factors for HCAP are outlined in Table 912.

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Definition & Pathogenesis
Three factors distinguish nosocomial pneumonia from CAP:
(1) different infectious causes;
(2)
different
antibiotic
susceptibility
patterns,
specifically, a higher incidence of drug resistance; and
(3) the patients underlying health status that puts them
at risk for more severe infections.

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Definition & Pathogenesis
Since access to the lower respiratory tract occurs primarily
through microaspiration, nosocomial pneumonia starts with
a change in upper respiratory tract flora. Colonization of the
pharynx and possibly the stomach with bacteria is the most
important step in the pathogenesis of nosocomial
pneumonia.

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Definition & Pathogenesis
Pharyngeal colonization is promoted by exogenous factors
(eg, instrumentation of the upper airway with nasogastric
and endotracheal tubes; contamination by dirty hands,
equipment, and contaminated aerosols; and treatment with
broad-spectrum antibiotics that promote the emergence of
drug-resistant organisms) and patient factors (eg,
malnutrition, advanced age, altered consciousness,
swallowing disorders, and underlying pulmonary and
systemic diseases).

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Definition & Pathogenesis
Within 48 hours of admission, 75% of seriously ill
hospitalized patients have their upper airway colonized with
organisms from the hospital environment.

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Definition & Pathogenesis
Impaired cellular and mechanical defense mechanisms in
the lungs of hospitalized patients raise the risk of infection
after aspiration has occurred.
Tracheal intubation increases the risk of lower respiratory
infection by mechanical obstruction of the trachea,
impairment of mucociliary clearance, trauma to the
mucociliary escalator system, and interference with
coughing.
Tight adherence of bacteria such as Pseudomonas to the
tracheal epithelium and the biofilm that lines the
endotracheal tube makes clearance of these organisms
from the lower airway difficult.

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Definition & Pathogenesis
The role of the stomach in the pathogenesis of HCAP
remains
controversial.
Observational
studies
have
suggested that elevation of gastric pH due to antacids, H2receptor antagonists, proton pump inhibitors (PPIs), or
enteral feeding is associated with gastric microbial
overgrowth, tracheobronchial colonization, and HAP/VAP.

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Definition & Pathogenesis
Sucralfate, a cytoprotective agent that does not alter
gastric pH, is associated with a trend toward a lower
incidence of VAP. The Infectious Disease Society of America
recommends
that acid suppressive medications (H2receptor antagonists and PPIs) only be given to patients at
high risk for stress gastritis.

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Definition & Pathogenesis
The microbiology of the nosocomial pneumonias differs
from CAP but is substantially the same among HAP, VAP,
and HCAP (Table 913).
The most common organisms responsible for HAP include:
S aureus (both methicillinsensitive S aureus and MRSA),
P aeruginosa,
gram-negative rods including non-extended spectrum blactamase (ESBL) producing and ESBL-producing
(Enterobacter species, K pneumoniae, and Escherichia
coli).

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Definition & Pathogenesis
VAP patients may be infected with:
Acinetobacter
species
and
Stenotrophomonas
maltophilia.
HCAP patients may have common organisms:
S pneumoniae, H influenzae that are more likely to be
drug resistant, or flora that resembles HAP.
Anaerobic organisms (bacteroides, anaerobic streptococci,
fusobacterium) may also cause pneumonia in the
hospitalized patient; when isolated, they are commonly part
of a polymicrobial flora.
Mycobacteria, fungi, chlamydiae, viruses, rickettsiae, and
protozoal organisms are uncommon causes of nosocomial
pneumonias.

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Clinical Findings
A. Symptoms and Signs
The symptoms and signs associated with nosocomial
pneumonias are nonspecific; however, two or more clinical
findings (fever, leukocytosis, purulent sputum) in the
setting of a new or progressive pulmonary opacity on chest
radiograph are approximately 70% sensitive and 75%
specific for the diagnosis of VAP in one study. Other findings
include those listed above for CAP.

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Clinical Findings
A. Symptoms and Signs
The differential diagnosis of new lower respiratory tract
symptoms and signs in hospitalized patients includes
congestive heart failure, atelectasis, aspiration, ARDS,
pulmonary thromboembolism, pulmonary hemorrhage, and
drug reactions.

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B. Laboratory Findings
Diagnostic evaluation for suspected nosocomial pneumonia
includes blood cultures from two different sites. Blood
cultures can identify the pathogen in up to 20% of all
patients with nosocomial pneumonias; positivity is
associated with increased risk of complications and other
sites of infection.
Blood counts and clinical chemistry tests do not establish a
specific diagnosis of HCAP; however, they help define the
severity of illness and identify complications.

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B. Laboratory Findings
The assessment of oxygenation by an arterial blood gas or
pulse oximetry determination helps define the severity of
illness and determines the need assisted ventilation.
Thoracentesis for pleural fluid analysis should be
considered in patients with be considered in patients with
pleural effusions.
Examination of sputum is attended by the same
disadvantages as in CAP. Gram stains and cultures of
neither sensitive nor specific in the diagnosis of nosocomial
pneumonias. The identification of a bacterial organism by
culture of sputum does not prove that the organism is a
lower respiratory tract pathogen. However, it can be used
to help identify bacterial antibiotic sensitivity patterns and
as a guide to adjusting empiric therapy.

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C. Imaging
Radiographic findings in HAP/VAP are nonspecific and often
confounded by other processes that led initially to
hospitalization or ICU admission.

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D. Special Examinations
Endotracheal aspiration using a sterile suction catheter and
fiberoptic bronchoscopy with bronchoalveolar lavage or a
protected specimen brush can be used to obtain lower
respiratory tract secretions for analysis, most commonly in
patients with VAP.
Endotracheal aspiration cultures have significant negative
predictive value but limited positive predictive value in the
diagnosis of specific infectious causes of HAP/VAP.

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D. Special Examinations
An invasive diagnostic approach using quantitative culture
of bronchoalveolar lavage samples or protected specimen
brush samples in patients in whom VAP is suspected leads
to significantly less antibiotic use, earlier attenuation of
organ dysfunction, and fewer deaths at 14 days.
Measurement of procalcitonin levels holds promise as a
noninvasive strategy to distinguish bacterial pneumonia
from noninfectious causes of fever with pulmonary
infiltrates in hospitalized patients.

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Treatment
Treatment of the nosocomial pneumonias, like treatment of
CAP, is usually empiric (Table 914). Because of the high
mortality rate, therapy should be started as soon as
pneumonia is suspected.
There is no consensus on the best regimens because this
patient population is heterogeneous and local flora and
resistance patterns must be taken into account.

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Treatment
After results of sputum, blood, and pleural fluid cultures are
available, it may be possible to de-escalate initially broad
therapy.
Duration of antibiotic therapy should be individualized
based on the pathogen, severity of illness, response to
therapy, and comorbid conditions.
Data from a large trial assessing treatment outcomes in
VAP suggest that 8 days of antibiotics is as effective as 15
days, except in cases caused by P aeruginosa.

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MUCHAS GRACIAS
POR SU ATENCION