The Definitions, epidemiology, diagnosis and management of hospital acquired pneumonia

1. Hospital Acquired Pneumonia
Khaled M. Taema
Ass. Professor of Critical Care Medicine
Cairo University
Egypt

2. Definitions

3. Pneumonia that occurs 48 hours or more after admission, which was
not incubating at the time of admission.
Hospital Acquired Pneumonia (HAP)
Pneumonia that arises more than 48–72 hours after endotracheal
intubation
Ventilator Associated Pneumonia (VAP)
Patient who was hospitalized in an acute care hospital for two or more
days within 90 days of the infection; resided in a nursing home or
long-term care facility; received recent intravenous antibiotic therapy,
chemotherapy, or wound care within the past 30 days of the current
infection; or attended a hospital or hemodialysis clinic
Healthcare Associated Pneumonia (HCAP)

4. There is increasing evidence from a growing number
of studies that many patients defined as having HCAP are
not at high risk for MDR pathogens.
Even if HCAP would be considered as a separate
clinical entity, it was thought that this could be included in
the upcoming community-acquired pneumonia (CAP)
guidelines because patients with HCAP, like those with
CAP, frequently present from the community and are
initially cared for in emergency departments.

5. The Magnitude of the problem

8. Attributable mortality is defined as the total mortality minus the
mortality associated with the underlying disease process.
Attributable endpoints
Attributable mortality
Attributable prolongation in ICU stay
--- etc.

13. 17 %
Attributable mortality
8.74
Days
P < 0.01
Attributable ↑ ICU stay Attributable ↑ hospital stay
11.45
Days
P < 0.01
Attributable ↑ Ventilator days
7.75
Days
P < 0.01

17. Diagnostic Dilemma

18. Clinical
Criteria
Biomarkers CPIS
S-TREM-1

19. Only CRP was studied in comparison to
clinical criteria.
None of the other biomarkers was studied in
comparison to clinical criteria

20. Procalcitonin CRP CPIS

22. Several studies evaluated the performance
characteristics of the different biomarkers in the
diagnosis of VAP
Meta-analysis of these studies done

23. Sensitivity Specificity Area Under
ROC
Procalcitonin 67 % 83 % 0.76
sTREM-1 84 % 49 % 0.78
CPIS 65 % 64 % 0.748
The performance characteristics of the different biomarkers in the
diagnosis of VAP

24. It is recommended to use clinical criteria alone
and not to use Procalcitonin, s-TREM, CRP or
CPIS to initiate antibiotic treatment in VAP

25. Microbiologic methods to diagnose
VAP and HAP

26. Invasive
Sampling
Non-invasive
Sampling
Quantitative
culture
Semi-
quantitative
culture

34. Invasive
Sampling
Non-invasive
Sampling
Quantitative
culture
Semi-
quantitative
culture
Vs

38. Primary outcome
28-Day mortality rate
Secondary outcomes
• ICU survival
• Hospital discharge
• ICU length of stay
• Hospital length of stay
• Change of antibiotic after culture

41. It is recommended to use endotracheal aspirate
with semi-quantitative cultures to diagnose VAP,
rather than invasive sampling with quantitative
cultures and rather than noninvasive sampling
with quantitative cultures

42. Risk Assessment

43. Patient
specific
Hospital
specific

44. Patient specific

45. Patients who develop VAP after >5 days of
HOSPITALIZATION are at higher risk of infection with
MDR organisms than patients who develop VAP earlier in
their hospitalization.

46. Hospital specific
• Units with local antibiogram showing >10%–20% of S. aureus isolates are
methicillin resistant
• Units where the prevalence of MRSA is not known
• Units with local antibiogram showing >10% of gram-negative isolates are
resistant to an agent being considered for monotherapy.
• Units where local antimicrobial susceptibility rates are not available.
For MRSA
For Pseudomonas

47. Prevention

48. Wean Early
Hand Hygiene
Aspiration Precautions

50. Treatment

51. Empiric Treatment

52. Selecting empiric treatments for clinically suspected VAP is a
difficult balancing act between starting adequate antibiotics early and
limiting superfluous coverage.
Delaying treatment and failing
to cover patients’ causative
pathogens are both associated
with higher mortality rates
Broader coverage and longer
treatment courses increase the
risks of adverse drug effects, C.
difficile infections, and
antimicrobial resistance

53. The generally recommended compromise is to pair
early and aggressive treatment with early and
aggressive de-escalation

54. Pseudomonas
and other gm
-ve
Staph.
Aureus
MRSA MSSA Mono Co
weak recommendation, very low-quality evidence

56. MRSA
Vancomycin
linezolid
MSSA
Piperacillin-
tazobactam
Cefepime
levofloxacin
Imipenem
Meropenem

62. gram -ve
Mono Co

63. avoiding aminoglycosides if alternative agents with
adequate gram-negative activity are available
Avoiding colistin if alternative agents with adequate
gram-negative activity are available

68. 0

69. Apart from worse clinical outcome
associated with Tigecycline and Doripenem,
The regimens tested either alone or in
combination reported no significant differences
between comparator arms.

70. Carbapenems
Non-
CabapenemsVs
22 %
Relative risk reduction of
mortality
No difference Clinical response Adverse events
No repots about subsequent C. Difficile infection and acquired
carbapenem resistance

72. Role of inhaled Antibiotic therapy

74. For patients with VAP due to gram-negative bacilli that
are susceptible to only aminoglycosides or polymyxins
(colistin or polymyxin B)
Use both inhaled and systemic antibiotics, rather than
systemic antibiotics alone
(weak recommendation, very low-quality evidence)

75. Pathogen-Specific Therapy

76. MRSA
Vancomycin
linezolid
P.
areuginosa
C & S
Against
Aminoglycosides
mono therapy
Mono Co
Septic shock
High risk for death (> 25 %)
Vs

77. Carbapenem
resistant
IV polymyxins
Adjunctive
inhaled Colistin
(strong recommendation,
moderate-quality evidence)
(week recommendation,
low-quality evidence)

78. De-escalation
Length of
therapy

79. De-escalation

84. Antibiotic therapy to be de-escalated
rather than fixed
Changing an empiric broad spectrum antibiotic regimen to a
narrower regimen by changing the antimicrobial agent or
changing from combination therapy to monotherapy.
De-escalation
Fixed Antibiotic
therapy
Maintaining a broad-spectrum antibiotic regimen until therapy
is completed.

85. Length of
therapy

88. A 7-day course of antimicrobial therapy
rather than a longer duration
(strong recommendation,
moderate-quality evidence).
Decision affected improvement of
clinical, radiologic, and laboratory
parameters.

89. Discontinuation
based on
Biomarkers or
CPIS

91. PCT-based decision making decreased antibiotic exposure and
was not associated with increased mortality or treatment failure

92. PCT levels plus clinical criteria but not CPIS can be
used to guide the discontinuation of antibiotic
therapy, rather than clinical criteria alone
(weak recommendation, low-quality evidence)