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nosocomial pneumonia; hospital-acquired pneumonia; health care-associated pneumonia

pneuomonia that occurs >= 48 hours after hospital admission, & not incubating at the time of admission Etiology: risk factors 1) host-related a) advanced age (>= 70 years of age) b) severity of illness c) trauma or head injury d) poor nutritional status, malnutrition e) coma f) impaired airway reflexes g) chronic obstructive pulmonary disease h) neuromuscular disease i) altered mental status j) previous antibiotic use k) pulmonary pathogens causing nososocomial pneumonia typically colonize dental plaque & pharyngeal mucosa [2] 2) device-related a) endotracheal tube, mechanical ventilation (strongest independent risk factor) [1] b) nasogastric tube c) bronchoscopy 3) drug-related a) immunosuppressive therapy b) peptic ulcer medications (H2 blockers) c) antibiotic use in the past 90 days associated with increased risk for: - MRSA, antibiotic-resistant Pseudomonas - other antibiotic resistant organisms [1] 4) miscellaneous a) thoracic or upper abdominal surgery b) duration of surgery c) duration of hospitalization 5) bacterial infections 24% - drug-resistant bacterial infections - methicillin-resistant Staphylococcus aureus - carbapenem-resistant Acinetobacter (fastest increasing 2019-2020) [12] - vancomycin-resistant Enterococcus 6) viruses in 22% [9] - rhinovirus (46% of viral infections) [9] - influenza - parainfluenza - coronavirus - metapneumovirus Clinical manifestations: - fever, hypoxemia, purulent sputum Laboratory: - complete blood count may show leukocytosis with left shift or leukopenia - sputum culture, blood cultures - multiplex PCR assay may become the new standard - pulse oximetry: decrease in SaO2 - arterial blood gas - see ARUP consult [3] Radiology: 1) new or progressive infiltrate on chest X-ray 2) consoidation or cavitation Complications: - readmissions similar for bacterial vs viral origin of nosocomial infection [9] Management: - also see ventilator-associated pneumonia - avoid endotracheal intubation if possible - use non-invasive positive pressure ventilation when feasible [1] - oral hygiene for hospitalized patients may reduce incidence of nosocomial pneumonia [1] - 7-8 days of antibiotic therapy for uncomplicated cases [1,10]; 7 days (MKSAP19) [1] - if patient does not improve within 3 days of appropriate antibiotic therapy, consider alternate diagnosis or unrecognized source of infection [1] - empiric coverage for Pseudomonas aeruginosa & MRSA standard [11] - discontinuation of MRSA coverage after 4 days if cultures are negative reduces ICU stay & duration of hospitalization - cefipime, Zosyn, or levofloxacin & nafcillin if low risk of MRSA [4] - use vancomycin or linezolid rather than nafcillin if risk of MRSA [4] - dual coverage with empiric therapy for Pseudomonas - single agent coverage appropriate if antibiotic sensitivity known [14] - 7 days of coverage for ventilator-associated pneumonia [14] - nursing home associated pneumonia - if facility has low rate of resistant organisms, no need to cover MRSA - levofloxacin rather than cefipime if patient to be treated in nursing home [13] Notes: - guidelines have not improved treatment precision [7]

Specific

ventilator-associated pneumonia

General

pneumonia (PNA) nosocomial infection; nursing home acquired infection

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  3. ARUP Consult: Hospital-Acquired and Ventilator-Associated Pneumonia The Physician's Guide to Laboratory Test Selection & Interpretation https://arupconsult.com/content/healthcare-associated-pneumonia
  4. Pugh R, Grant C, Cooke RP, Dempsey G. Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults. Cochrane Database Syst Rev. 2011 Oct 5;(10):CD007577 PMID: 21975771
  5. Opal SM. ACP Journal Club. Review: Short-course antibiotics in hospital-acquired pneumonia do not affect mortality. Ann Intern Med. 2012;156(6):JC3-13. PMID: 22431699
  6. Agency for Healthcare Research & Quality (AHRQ) Pharmacokinetic/Pharmacodynamic Measures for Guiding Antibiotic Treatment for Hospital-Acquired Pneumonia. Research Review - Final - Nov. 24, 2014 http://www.effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=2008
  7. Jones BE et al. Trends in antibiotic use and nosocomial pathogens in hospitalized veterans with pneumonia at 128 medical centers, 2006-2010. Clin Infect Dis 2015 Nov 1; 61:1403 PMID: 26223995 http://cid.oxfordjournals.org/content/61/9/1403 - Mortensen EM. Editorial commentary: The mismatch between physicians' expectations and microbiologic reality. Clin Infect Dis 2015 Nov 1; 61:1411 PMID: 26223996 http://cid.oxfordjournals.org/content/61/9/1411
  8. Patel PJ, Leeper KV Jr, McGowan JE Jr. Epidemiology and microbiology of hospital-acquired pneumonia. Semin Respir Crit Care Med. 2002 Oct;23(5):415-25. PMID: 16088635
  9. Shorr AF, Zilberberg MD, Micek ST, Kollef MH. Viruses are prevalent in non-ventilated hospital-acquired pneumonia. Respir Med 2017 Jan; 122:76. PMID: 27993295
  10. Madaras-Kelly KJ, Burk M, Caplinger C et al. Total duration of antimicrobial therapy in veterans hospitalized with uncomplicated pneumonia: Results of a national medication utilization evaluation. J Hosp Med 2016 Dec; 11:832. PMID: 27527659
  11. Cowley MC, Ritchie DJ, Hampton N, Kollef MH, Micek ST. Outcomes associated with de-escalating therapy for methicillin- resistant Staphylococcus aureus in culture-negative nosocomial pneumonia. Chest 2019 Jan; 155:53. PMID: 30621854
  12. Rapid Review Quiz: Hospital-Acquired Pneumonia Medscape. Sept 15, 2022 https://reference.medscape.com/viewarticle/980567
  13. Mylotte M Nursing Home-Associated Pneumonia, Part I: Diagnosis. JAMDA. 2019. June 6. https://www.jamda.com/article/S1525-8610(19)30388-3/fulltext - Mylotte M Nursing Home-Associated Pneumonia, Part II: Etiology and Treatment. JAMDA. 2020. June 6.
  14. NEJM Knowledge+