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Definition
HAP:
Arises 48 hours or more after hospital admission
Not incubated at the time of admission
Ventilator-associated pneumonia (VAP):
Arises 48-72 hours or more after endotracheal intubation
Healthcare-associated pneumonia (HCAP):
Arises within 90 d of having been admitted to an acute care facility
Has resided in a nursing home or LTCF or
Received I.V antimicrobial therapy, chemotherapy or wound care
within the 30 d prior to the current infection or
Attends a hospital or hemodialysis clinic
Epidemiology
Usually caused by bacteria, is currently the second most common
nosocomial infection in the US
Has an associated crude mortality of 30-70%
Occurs at a rate of approximately 5-10 cases per 1000 hospital
admissions
Incidence increases by 6-20 fold in patients being ventilated
mechanically
HAP accounts for up to 25% of all ICU infections and for more than
50% of the antibiotics prescribed
Incidence of Nosocomial Infections in Combined Medical-
Surgical ICU’s
Medical Patients Surgical Patients
Early-onset Late-onset
Early-onset HAP and VAP, usually carry a better prognosis, and are
more likely to be caused by antibiotic sensitive bacteria
Late-onset HAP and VAP are more likely to be caused by multidrug-
resistant(MDR) pathogens, and are associated with increased patient
mortality and morbidity
Early-onset HAP with risk factors for MDR pathogens are at greater
risk for colonization and infection with MDR pathogens and should be
treated similar to patients with late-onset HAP or VAP
Etiology
Causative Pathogens in Causative Pathogens in
patients with Early onset or patients with Late onset or
No Risk factors for MDR Risk factors for MDR
Pathogens Pathogens
Timing Within five days of admission or Five days or more after admission or
mechanical ventilation mechanical ventilation
Bacteriology Streptococcus pneumonia Same as before
Haemophilus influenzae Pseudomonas aeruginosa
Anaerobic bacteria Acinetobacter sp.
MSSA MRSA
Escherichia coli
Klebsiella pneumoniae Klebsiella pneumoniae-ESBL
Enterobacter species Legionella pneumophila
Proteus species
Serratia species
Prognosis Less severe, little impact on outcome Higher attributable mortality and
Mortality minimal morbidity
Diagnosis
Not necessarily easy to accurately diagnose HAP
Criteria frequently include:
Clinical
Fever ; cough with purulent sputum,
Radiographic
New or progressive infiltrates on CXR,
Laboratorial
Leukocytosis or leukopenia
Microbiologic
Suggestive gram stain and positive cultures of sputum, tracheal
aspirate, bronchial brushing, pleural fluid or blood
Therapeutic Failure
or Inadequate
Antibiotic
Mortality
Therapy
Antibiotic
Resistance
Importance of Appropriate Initial Therapy
“…selection of initial appropriate antibiotic therapy (ie, getting the antibiotic
treatment right the first time) is an important aspect of care for hospitalized
patients with serious infections.” – ATS/IDSA Guidelines
A Study by Kollef and Colleagues Evaluating the Impact of Inadequate
Antimicrobial Therapy on Mortality (CAP/HAP, 655 ICU Patients)
60
52* *P <.001
Hospital Mortality (%)
50
42*
40
30 24
18
20
10
0
All-Cause Mortality Infection-Related Mortality
Inadequate antimicrobial treatment (n=169) Adequate antimicrobial treatment (n=486)
ATS/IDSA. Am J Respir Crit Care Med. 2005;171:388-416.
Chest. 1999;115:462-474.
Antibiotic Selection
General Approach (clinical decision initiate therapy)
No Yes
Linezolid is an alternative to vancomycin for the treatment of MRSA VAP and may be
preferred on the basis of a subset analysis of two prospective randomized trials
(BUT? VANCO trough & Patients Comorbidities)
This agent may also be preferred if:
Patients have renal insufficiency or
Receiving other nephrotoxic agents, but more data are needed
If Acinetobacter species are documented to be present, the most active agents are the
carbapenems, sulbactam, colistin, & polymyxin
There are no data documenting an improved outcome if these organisms are treated with
combination regimen
Combination vs. Monotherapy
Combination therapy is common practice in the therapy of suspected and
proven gram-negative HAP (B- lactam–aminoglycoside)
Synergism
Clearly documented to be valuable only in vitro and in patients with
neutropenia or bacteremic infection
Prevention of resistance (P. aeruginosa, Enterobacter)
Not well documented
Nephrotoxicity
Complication
Empyema or Lung Abscess
Clostridium difficile Colitis
Occult Infection
Drug Fever