Definition Of Groups Of Patients
The ATS guidelines stratify patients with HAP into three groups, according to its severity, time of onset, and presence or absence of specific risk factors. All patients exhibiting HAP, whether the pneumonia is ventilator associated or not, are classified. Group 1 includes patients without unusual risk factors who present with mild-to-moderate HAP with onset at any time during hospitalisation or severe HAP with early onset. Group 2 includes patients with specific risk factors who present with mild-to-moderate HAP occurring at any time during hospitalisation. Group 3 includes patients with severe HAP either of early onset with specific risk factors or of late onset . As previous antimicrobial treatment is a risk factor for selecting resistant pathogens, subjects in group 3 were further divided into subgroups according to the absence or presence of prior antibiotic within 1 month before HAP.
Common Causes Of Hospital
Common bacteria involved in hospital-acquired pneumonia include the following :
- P aeruginosa
- Staphylococcus aureus, including methicillin-susceptible S aureus and methicillin-resistant S aureus
- Klebsiella pneumoniae
- Escherichia coli
- Non-Enterobacteriaceae bacteria such as S.and Acinetobacter species are less common causes.Acinetobacter species commonly colonize respiratory tract secretions in patients in the ICU. HAP caused by Acinetobacter species or B cepacia may be associated with outbreaks. Streptococcus pneumoniae and Haemophilus influenzae are recovered only in early-onset HAP.
Organisms Associated With Ventilator
Organisms associated with ventilator-associated pneumonia include the following:
- P aeruginosa
- S Aureus, including MSSA and MRSA
- S maltophilia
- Acinetobacter species
- Enterobacteriaceae are less commonly seen in VAP than in hospital-acquired pneumonia
These organisms are commonly recovered from respiratory secretions in patients with VAP. The recovery of a respiratory pathogen from respiratory secretions does not establish it as the cause of nosocomial pneumonia. MSSA/MRSA frequently colonize respiratory secretions in intubated patients but rarely, if ever, cause nosocomial pneumonia/VAP. In contrast, MSSA/MRSA may cause community-acquired pneumonia in those with influenza. Anaerobic organisms are not important pathogens in nosocomial pneumonia.
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If You Decide The Patient Has Hap How Should The Patient Be Managed
Once you have decided your patient has HAP, the clinician should take into consideration the following treatment pearls:
Establish need for respiratory or hemodynamic support for unstable patients
Obtain microbiologic samples from sputum, tracheal aspirates or bronchoscopy and obtain blood cultures
Review your local antibiogram for resistance patterns
Determine risk for infection with MRSA and need for antibiotics targeting MRSA
Determine mortality risk. If low risk treat with one antipseudomonal antibiotic.
If risk for mortality is high, treat with two antipseudomonal antibiotics from different classes.
Consider empiric treatment as above during initial treatment, especially if microbiologic studies are pending. De-escalate and narrow antibiotics according to culture identification of microorganisms and their sensitivities.
Pneumonia is associated with complications such as acute respiratory failure and septic shock. Ensuring patients with HAP have adequate support to maintain oxygenation and ventilation and a mean arterial blood pressure sufficient to perfuse vital organs is paramount.
Adopted from Kalil et al. Empiric antibiotic choice based on risk of mortality and infection with MRSA.
How Is Hap Diagnosed
Your healthcare provider will listen to your lungs for abnormal sounds. You may also need any of the following:
- Blood tests are used to check for infection.
- An x-ray or CT scan may show infection, and how well your lungs are working. They may also show other problems, such as fluid around your lungs. You may be given contrast liquid to help your lungs show up better in the pictures. Tell the healthcare provider if you have ever had an allergic reaction to contrast liquid.
- A sputum sample may be tested for the germ that is causing your illness. It can help your healthcare provider choose the best medicine to treat the infection.
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Stress Bleeding Prophylaxis Transfusion And Glucose Control
Histamine type 2 antagonists and antacids have been identified as independent risk factors for ICU-acquired pneumonia. Sucralfate has been used for stress bleeding prophylaxis, as it does not decrease intragastric acidity or significantly increase gastric volume. Comparative data from randomized trials suggest a trend toward reduced VAP with sucralfate, but there is a slightly higher rate of clinically significant gastric bleeding, compared with H2 antagonists. If needed, stress bleeding prophylaxis with either H2 antagonists or sucralfate is acceptable .
Modulation Of Colonization: Oral Antiseptics And Antibiotics
Oropharyngeal colonization, either present on admission or acquired during ICU stay, has been identified as an independent risk factor for the development of ICU-acquired pneumonia caused by enteric gram-negative bacteria and P. aeruginosa . In a randomized trial, the use of the oral antiseptic chlorhexidine significantly reduced the rates of nosocomial infection in patients undergoing coronary artery bypass surgery . Modulation of oropharyngeal colonization, by combinations of oral antibiotics, with or without systemic therapy, or by selective decontamination of the digestive tract , is also effective in significantly reducing the frequency of HAP, although methodologic study quality appeared to be inversely related to the magnitude of the preventive effects .
Routine prophylaxis of HAP with SDD, with or without systemic antibiotics, reduces the incidence of ICU-acquired pneumonia, has helped contain outbreaks of multi-drug resistant bacteria), but is not recommended for routine use, especially in patients who may be colonized with multi-drug resistant pathogens.
In summary, prior administration of systemic antibiotics has reduced the risk of nosocomial pneumonia in some patient groups, but if a history of prior administration is present at the time of onset of infection, there should be increased suspicion of infection with MDR pathogens .
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What Puts You At Risk For Hospital
You can get hospital-acquired pneumonia when you are in a hospital. You are more likely to get it if you:
- Have another serious condition, especially another lung disease, such as COPD.
- Aren’t eating enough healthy foods and are malnourished.
- Have a weak immune system.
- Have been in the hospital for a long time.
- Are taking many antibiotics.
- Are 55 or older.
The Surprising Cause Of Hospital
And how a small team of nurses and researchers found the answer to a not-so-easy question
Hospitals should be places of healing, but far too often, patients develop infections before they can be discharged. In fact, hospital-acquired infections are among the most common hospital-related complications, affecting 1 in 25 patients, according to The New England Journal of Medicine. And they’re largely preventable.
Hospital-acquired infections have been a point of emphasis since 2009, when the U.S. Department of Health and Human Services released its National Action Plan to Prevent Healthcare-Associated Infections. Not surprisingly, that plan focused primarily on infections related to catheters, ventilators and surgery sites.
“They were the easiest to recognize, the easiest to track and the easiest to monitor, because the patient has a device,” says nursing professor Dian Baker of Sacramento State University. “Hospitals have had a fairly good track record of reducing all those infections because if they didn’t, they were penalized.”
That’s the good news. The bad news is that the Action Plan didn’t address the number-one hospital-acquired infection: non-ventilator hospital-acquired pneumonia . It took the work of Baker and a group of other health care professionals, most of them nurses, to do that.
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Microbiologic Approach To Diagnosing Ventilator
For patients with suspected VAP, sampling of the lower airways for quantitative cultures can be obtained through the following methods:
- Blind tracheobronchial aspiration can be done by inserting a flexible catheter into the distal trachea however, since it is blind sampling, there is no direct sampling of the lung in which radiographic evidence shows infiltrates. Furthermore, as the catheter is inserted through the endotracheal tube, there is a risk of contamination leading to false-positive results.
- Bronchoscopy with bronchoalveolar lavage allows for direct sampling of the lung segments with radiographic evidence of infiltrates. Limitations of the technique include operator-skill, contamination, and risk of worsening hypoxemia.
- Protected specimen brush can be advanced through a bronchoscope to avoid upper airway contamination.
What Is Hospital Acquired Pneumonia
Hospital-acquired pneumonia is a lower respiratory bacterial infection that occurs 48 hours or more after hospital admission. Hospital-acquired pneumonia , also known as nosocomial pneumonia, is a lower respiratory bacterial infection that occurs 48 hours or more after hospital admission and does not appear due to intubation at the time of admission.People experience
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Hospital-acquired pneumonia , also known as nosocomial pneumonia, is a lower respiratory bacterial infection that occurs 48 hours or more after hospital admission and does not appear due to intubation at the time of admission.
People experience a host of symptoms ranging from fever and chills to shortness of breath and chest pain and are at higher risk of developing severe complications and even death. Infections are also much more likely in older adults and those who have poor health or are immunocompromised.
This article discusses the symptoms, causes, diagnosis, and treatment of hospital-acquired pneumonia.
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Physiotherapy And Other Management
Other health professionals will be treating your patient. What is their input?When addressing HAP, respiratory physiotherapy interventions should be individually tailored around the patients symptoms, observing aspects such as degree of pain, mobility capabilities and an array of complex factors. Therefore techniques may include positional manipulations , manual hyperinflation, percussion, shaking, vibrations, suctioning , breathing exercises including thoracic expansion and relaxing tidal volumes, while also engaging sputum reduction through active cycle and autogenic drainage techniques) as well as mobilization. The later of course demonstrating great importance not only in terms of improving the patients respiratory distress, but also in reducing overall hospitalization.Published substantial evidence very much supports the role of physiotherapy in the respiratory managing HAF, demonstrating both short-term and longer term benefits. However, its essential to promote physiotherapy treatment as part of a multi-disciplinary approach as aspects including pharmaceutical interventions play an integral part in controlling bacterial diseases, promoting lung function and reducing problematic symptoms.
Beware: There Are Other Diseases That Can Mimic Healthcare
It is important to consider other diagnoses when considering HAP. Atelectasis, CHF, ARDS, pulmonary embolus with infarction, pulmonary hemorrhage, lung contusion , and aspiration pneumonitis can all mimic pneumonia. The 2016 IDSA/ATS guidelines recommend that clinical criteria with a new lung infiltrate be used to diagnosis HAP however, as mentioned above, the clinical findings are nonspecific. Clinical criteria include new onset fever, leukocytosis, hypoxia and purulent sputum. When assessing the accuracy of different clinical criteria to diagnose VAP, one study showed that the presence of a new or progressive infiltrate plus â¥2 clinical features, either fever, leukocytosis or purulent sputum, resulted in a 69% sensitivity and 75% specificity for the diagnosis of pneumonia. The clinical pulmonary infection score which includes the previously mentioned clinical criteria plus oxygenation and tracheal aspirate has not been shown to be superior to conventional clinical criteria. Non-invasive and invasive sampling techniques have diagnostic values comparable to clinical criteria.
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Signs And Symptoms Of Hospital
Signs and symptoms of hospital-acquired pneumonia include the following:
- Persistent cough
- Fever, which may be mild or high
- Sweating and shaking chills
- Shortness of breath, which may only occur when you climb stairs
- Nausea, vomiting, or diarrhea
Seniors over 65 and people in poor health may have a lower body temperature. Older people can also experience sudden changes in mental awareness. Hospital-acquired pneumonia can even be a life-threatening to seniors.
Are You Sure Your Patient Has Hospital
Clinical features of HAP are indistinguishable from other forms of pneumonia. Patients will often present with cough, pleuritic chest pain, dyspnea and sputum production. Less specific symptoms include fevers, rigors, chills and fatigue. Other less common features are headache, nausea, vomiting, diarrhea and myalgias.
For CAP, 80% of patients have fevers and 45-70% of patients have tachypnea. One study demonstrated a negative likelihood ratio of 0.18 for the diagnosis of pneumonia if heart rate, respiratory rate and temperature were normal. If the prevalence of pneumonia is 5% in the population, a patient with normal vital signs would have a < 1% probability of pneumonia. Tachypnea and tachycardia may be a more sensitive sign of pneumonia in older adults who are less likely to have increases in temperature. The elderly population is also more at risk for mental status changes which may be an indication of an underlying infection such as pneumonia.
On exam if there is consolidation in the lungs, dullness to percussion and increased tactile fremitus may be felt over the area of consolidation. On auscultation, crackles are found in 80% of patients with pneumonia. Whispered pectoriloquy, an increased loudness of a whisper, and egophony, an increased resonance or nasal quality of sounds, may be present in patients with pneumonia. Although these findings are helpful, there is no single exam finding that can rule in or out pneumonia.
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Aspiration Body Position And Enteral Feeding
Supine patient positioning may also facilitate aspiration, which may be decreased by a semirecumbent positioning. Using radioactive labeled technetium instilled into the stomach, cumulative radioactive counts of endotracheal secretions were higher when patients were placed in the supine position . One randomized trial demonstrated a reduction in the incidence of ICU-acquired HAP in patients treated in the semirecumbent position compared with patients treated completely supine . Infection in patients in the supine position was strongly associated with the simultaneous administration of enteral nutrition. Thus, intubated patients should be kept in the semirecumbent position rather than supine to prevent aspiration, especially when receiving enteral feeding.
Diet Activity And Deterrence
Many patients with nosocomial pneumonia have significant nutritional deficiencies. Early enteral nutrition appears to decrease infectious complications. Parenteral nutrition does not seem to have this effect and should be considered only in patients with a contraindication to enteral replacement.
Beds that permit some degree of patient turning may decrease the likelihood of hospital-acquired pneumonia /ventilator-associated pneumonia in at-risk patients. Decontamination of the mouth and gut may affect the risk of producing MDR organisms.
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The Impact Of Hospital
As the name implies, non-ventilator hospital-acquired pneumonia occurs in patients who may get nowhere near an operating room. And yet it’s a deadly serious problem. According to a Baker co-authored for the journal Infection Control & Disease Epidemiology this year, it “has a crude mortality rate of 15%30%, extends hospital length-of-stay by up to 15 days, requires ICU admission in up to 46% of non-ICU cases, increases antibiotic utilization and is associated with readmission within 30 days in up to 20% of survivors.”
After the Action Plan came out, hospitals including Sutter Medical Center in Sacramento and Salem VA Medical Center in Salem, Va. began studying their hospital-acquired pneumonia rates. They were surprised at how prevalent the problem was.
For example, Sutter Medical Center found 115 cases over a 12-month period. Twenty-three patients died, including a healthy 57-year-old who had no risk factors after routine surgery.
And across the country, oral care was viewed merely as a comfort measure, similar to brushing a patient’s hair.
According to Baker, those results prompted an urgent question: How did germs get into those patients’ lungs? “This was 2010, and I’m telling you that was not an easy question to answer,” she says.
Within 48 hours of hospitalization, dangerous bacteria can take over microorganisms in the mouth, upsetting the normal balance. And some of those bacteria are microaspirated into the lungs, causing pneumonia.
Intubation And Mechanical Ventilation
Intubation and mechanical ventilation is associated to increased risk of HAP and therefore should be avoided whenever possible . Non-invasive positive-pressure ventilation is an attractive alternative for patients with acute exacerbations of chronic obstructive pulmonary disease or acute hypoxemic respiratory failure, and for some immunosuppressed patients with pulmonary infiltrates and respiratory failure .
Reduced duration of intubation and mechanical ventilation may prevent VAP. Specific strategies have been recommended in order to reduce the duration of mechanical ventilation, such as improved methods of sedation and the use of protocols to facilitate and accelerate weaning .
Attention to the specific type of endotracheal tube, its maintenance, and the site of insertion may also be valuable. Orotracheal intubation and orogastric tubes are preferred over nasotracheal intubation and nasogastric tubes in order to prevent nosocomial sinusitis and to reduce the risk of VAP, although direct causality has not been proved .
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What Other Considerations Exist For Patients With Hap
Patients who meet diagnostic criteria for pneumonia may not have an infectious etiology for their symptoms. Acute exacerbations of inflammatory lung diseases can mimic clinical pneumonia. Input from a pulmonologist in patients with inflammatory lung diseases is advised. Patients who present with recurrent, non-resolving pneumonia should be considered for possible malignancy as the etiology for their symptoms.
Table I is adapted from Kalil et al. Empiric antibiotic choice based on risk of mortality and infection with MRSA. High-risk mortality includes ventilator-dependent respiratory failure or septic shock. High-risk MRSA includes prior culture positive for MRSA, > 20% S. aureus isolated as MRSA in the unit, or IV antibiotic exposure within the prior 90 days. MRSA: methicillin-resistant Staphylococcus aureus.
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