Hospital acquired pneumonia

1. Hospital Acquired
Pneumonia

2. • Definition : Pneumonia developing >48 hours after hospital admission
• Etiology : organisms that colonize the pharynx of the hospitalized, critically ill
patient.
1. S. aureus
2. enteric (eg: K. pneumoniae or E. coli)
3. nonenteric (eg: P. aeruginosa) gram-negative bacilli
* Patients with longer lengths of hospital admission or IV antibiotic use within the
previous 90 days prior to the development of HAP are more likely to have MDR
organisms.

3. • Risk Factors :
• Witnessed aspiration
• COPD, ARDS, or coma
• Administration of antacids, H2-antagonists, or proton
pump inhibitor
• Supine position
• Enteral nutrition, nasogastric tube
• Reintubation, tracheostomy, or patient transport
• Head trauma, ICP monitoring
• Age >60 years
• MDR risk (eg: MRSA, MDR Pseudomonas) if IV antibiotic
use within 90 days

4. • Diagnosis of HAP:
1. Presence of a new infiltrate on chest radiograph,
2. Fever
3. worsening respiratory status
4. the appearance of thick, neutrophil-laden respiratory
secretions

5. Treatment
• Empirically :
1- MSSA & MRSA
• If Patient have risk for MRSA infection ,we recommend
vancomycin or linezolid rather than an alternative
antibiotic
• For patients with HAP who are being treated empirically
and have no risk factors for MRSA infection and are not at
high risk of mortality ,regimen including piperacillin-
tazobactam, cefepime, levofloxacin, imipenem, or
meropenem
*Oxacillin, nafcillin, or cefazolin

6. 2- For patients with HAP who are being treated empirically and
have factors increasing the likelihood for Pseudomonas or other
gram-negative infection
we suggest prescribing antibiotics from 2 different classes with
activity against P. aeruginosa, BUT All other patients with HAP
who are being treated empirically may be prescribed a single
antibiotic with activity against P. aeruginosa.

7. • Pathogen specific treatment :
1- MRSA
either vancomycin or linezolid
2- PA
Double coverage (risk factors):
i. patients in units where >10% of gram-negative isolates are
resistant to an agent being considered for monotherapy,
ii. structural lung disease( bronchiectasis or cystic fibrosis)
iii. ICU Patients
iv. if IV antibiotic use within 90 days
v. Septic Shock

8. 3- Acinetobacter Species:
I. treatment with either a carbapenem or ampicillin/sulbactam
if the isolate is susceptible to these agents
II. we recommend intravenous polymyxin (colistin or polymyxin
B),If Acinetobacter species that is sensitive only to polymyxins
III. Acinetobacter species that is sensitive only to colistin, we
suggest not using adjunctive rifampicin
IV. HAP/VAP caused by Acinetobacter species, we recommend
against the use of tigecycline
4-Carbapenem-Resistant Pathogens :
we recommend intravenous polymyxins (colistin or polymyxin
B) ,IF carbapenem-resistant pathogen that is sensitive only to
polymyxins

9. • Duration of therapy :
we recommend a 7-day course of antimicrobial therapy
shorter or longer duration of antibiotics may be indicated,
depending upon the rate of improvement of clinical,
radiologic, and laboratory parameters

10. HAP Usual Pathogens Empirical Therapy
No risk factors for MDR pathogens (single
agent Pseudomonal coverage)
S. pneumoniae, H. influenzae, MSSA, enteric gram-
negative bacilli
Piperacillin/tazobactam
Cefepime
levofloxacin,
imipenem
Meropenem
Risk factors for MDR pathogen (dual
agent Pseudomonal coverage)
P. aeruginosa, K.
pneumoniae (ESBL), Acinetobactersp.
If MRSA or Legionella sp. suspected
Antipseudomonal
cephalosporine or
antipseudomonal carbapenem
or β-lactam/β-lactamase +
antipseudomonal
fluoroquinoloned or AMGg
Above + vancomycin or linezolid

11. THE END