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Hospital-acquired pneumonia

Background

Overview

Definition
HAP (nosocomial pneumonia) is a lower respiratory infection occurring in patients at least 48 hours after admission to the hospital, or within 14 days after discharge from the hospital.
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Pathophysiology
The three main infection routes include inhalation (most common), aspiration and hematogenous dissemination (rare). HAP is most frequently caused by S. aureus (especially, MRSA), Pseudomonas species (especially P. aeruginosa), Acinetobacter species, E. coli, and Klebsiella species (including extended-spectrum β-lactamase-producing and extensively drug-resistant Enterobacteriaceae). Other pathogens include S. maltophilia, Chryseobacterium species, E. meningoseptica.
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Epidemiology
The incidence of HAP (HAP) in the US is estimated at 363 per 100,000 patient-days.
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Disease course
Clinical manifestations of HAP are similar to community-acquired pneumonia. Typical pneumonia is characterized by severe malaise, fever, chills, productive cough with purulent sputum (yellow-greenish), dyspnea, and pleuritic chest pain associated with rales and increased tactile fremitus. Atypical HAP presents with extrapulmonary manifestations (eg. myalgia, nervous system impairment, and gastrointestinal symptoms).
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Prognosis and risk of recurrence
Prognosis of HAP is highly dependent on risk factors and comorbidities. However, multidrug-resistant HAP is associated with higher mortality.
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Guidelines

Key sources

The following summarized guidelines for the management of hospital-acquired pneumonia are prepared by our editorial team based on guidelines from the British Thoracic Society (BTS 2023), the European Society of Intensive Care Medicine (ESICM/ALAT/ERS/ESCMID 2017), the Infectious Diseases Society of America (IDSA/ATS 2016), and the Infectious Diseases Society of America (IDSA 2011,2007). ...
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Medical management

Initiation of treatment: as per ATS/IDSA 2016 guidelines, use clinical criteria alone to decide whether or not to initiate antibiotic therapy in patients with suspected HAP.
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More topics in this section

  • Empiric antibiotic therapy (general principles)

  • Empiric antibiotic therapy (MSSA coverage)

  • Empiric antibiotic therapy (MRSA coverage)

  • Empiric antibiotic therapy (Pseudomonas coverage)

  • Definitive antibiotic therapy (general principles)

  • Definitive antibiotic therapy (MSSA)

  • Definitive antibiotic therapy (MRSA)

  • Definitive antibiotic therapy (P. aeruginosa)

  • Definitive antibiotic therapy (ESBL-producing pathogens)

  • Definitive antibiotic therapy (carbapenem-resistant pathogens)

  • Definitive antibiotic therapy (Acinetobacter species)

  • Duration of treatment

Inpatient care

Clinical monitoring: as per ALAT/ERS/ESCMID/ESICM 2017 guidelines, obtain routine bedside clinical assessment with the following in patients with HAP receiving antibiotic therapy
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temperature monitoring
measurement of tracheobronchial secretion volume
culture and purulence assessment of tracheobronchial secretions
evaluation for CXR resolution
WBC count
paO2/FiO2
assessment of ≥ 1 clinical scores, such as CPIS, ODIN, SOFA, SAPS II, and APACHE II.

More topics in this section

  • Laboratory monitoring

Specific circumstances

Patients with aspiration pneumonia, diagnosis: as per BTS 2023 guidelines, recognize that aspiration pneumonia is particularly common in persons with a learning disability, in older persons, and in patients with neurological or upper gastrointestinal conditions.
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More topics in this section

  • Patients with aspiration pneumonia (maintenance of oral health)

  • Patients with aspiration pneumonia (management of swallowing difficulties)

  • Patients with aspiration pneumonia (choice of antibiotics)

  • Patients with aspiration pneumonia (thromboprophylaxis)

  • Patients with aspiration pneumonia (supportive and palliative care)

Quality improvement

Local susceptibility assessments: as per ATS/IDSA 2016 guidelines, ensure regular generation and dissemination of local antibiograms in all hospitals, ideally tailored to their HAP population, if possible.