Hospital-acquired pneumonia

Hospital-acquired pneumonia (HAP) or nosocomial pneumonia refers to any pneumonia contracted by a patient in a hospital at least 48–72 hours after being admitted. It is usually caused by a bacterial infection, rather than a virus.^[1][2]

HAP is the second most common nosocomial infection (urinary tract infection is the most common) and accounts for 15–20% of the total.^[1][2][3] It is the most common cause of death among nosocomial infections and is the primary cause of death in intensive care units.^[1][3]

HAP typically lengthens a hospital stay by 1–2 weeks.^[1][3]

Signs and symptoms

New or progressive infiltrate on the chest X-Ray with one of the following:^[3]

• Fever > 37.8 °C (100 °F)
• Purulent sputum
• Leucocytosis > 10.000 cells/μl

Types

• Bacterial pneumonia: The majority of cases related to various gram-negative bacilli (52%) and S. aureus (19%), usually of the MRSA type.^[4] Others are Haemophilus spp. (5%). In the ICU results were S. aureus(17.4%), P. aeruginosa (17.4%), Klebsiella pneumoniae and Enterobacter spp. (18.1%), and Haemophilus influenzae (4.9%).^[1]

• Viral pneumonia: influenza and respiratory syncytial virus and, in the immunocompromised host, cytomegalovirus- cause 10-20% of infections.^[2]

Ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) is a sub-type of hospital-acquired pneumonia (HAP) which occurs in people who are receiving mechanical ventilation. VAP is not characterized by the causative agents; rather, as its name implies, definition of VAP is restricted to patients undergoing mechanical ventilation while in a hospital. A positive culture after intubation is indicative of ventilator-associated pneumonia and is diagnosed as such. In order to appropriately categorize the causative agent or mechanism it is usually recommended to obtain a culture prior to initiating mechanical ventilation as a reference.

Risk factors

Among the factors contributing to contracting HAP are mechanical ventilation (ventilator-associated pneumonia), old age, decreased filtration of inspired air, intrinsic respiratory, neurologic, or other disease states that result in respiratory tract obstruction, trauma, (abdominal) surgery, medications, diminished lung volumes, or decreased clearance of secretions may diminish the defenses of the lung. Also, poor hand-washing and inadequate disinfection of respiratory devices cause cross-infection and are important factors.^[1][3]

Pathogenesis

Most nosocomial respiratory infections are caused by so-called skorvatch microaspiration of upper airway secretions, through inapparent aspiration, into the lower respiratory tract. Also, "macroaspirations" of esophageal or gastric material is known to result in HAP. Since it results from aspiration either type is called aspiration pneumonia.^[1][2][3]

Although gram-negative bacilli are a common cause they are rarely found in the respiratory tract of people without pneumonia, which has led to speculation of the mouth and throat as origin of the infection.^[1][2]

Diagnosis

Pneumonia as seen on chest x-ray. A: Normal chest x-ray. B: Abnormal chest x-ray with shadowing from pneumonia in the right lung (left side of image).

In hospitalised patients who develop respiratory symptoms and fever one should consider the diagnosis. The likelihood increases when upon investigation symptoms are found of respiratory insufficiency, purulent secretions, newly developed infiltrate on the chest X-Ray, and increasing leucocyte count. If pneumonia is suspected material from sputum or tracheal aspirates are sent to the microbiology department for cultures. In case of pleural effusion thoracentesis is performed for examination of pleural fluid. In suspected ventilator-associated pneumonia it has been suggested that bronchoscopy(BAL) is necessary because of the known risks surrounding clinical diagnoses.^[1][3]

Differential diagnosis

• Atelectasis
• Congestive heart failure
• Pulmonary embolism

Treatment

Usually initial therapy is empirical.^[3] If sufficient reason to suspect influenza, one might consider oseltamivir. In case of legionellosis, erythromycin or fluoroquinolone.^[1]

A third generation cephalosporin (ceftazidime) + carbapenems (imipenem) + beta lactam & beta lactamase inhibitors (piperacillin/tazobactam)

A study showed that gastric feed supplementation with ginger extract might help reduce the incidence nosocomial pneumonia.^[5]

References

1. ^ ^{a b c d e f g h i j} Mandell's Principles and Practices of Infection Diseases 6th Edition (2004) by Gerald L. Mandell MD, MACP, John E. Bennett MD, Raphael Dolin MD, ISBN 0-443-06643-4 · Hardback · 4016 Pages Churchill Livingstone
2. ^ ^{a b c d e} The Oxford Textbook of Medicine Edited by David A. Warrell, Timothy M. Cox and John D. Firth with Edward J. Benz, Fourth Edition (2003), Oxford University Press, ISBN 0-19-262922-0
3. ^ ^{a b c d e f g h} Harrison's Principles of Internal Medicine 16th Edition, The McGraw-Hill Companies, ISBN 0-07-140235-7
4. ^ Table 13-7 in: Mitchell, Richard Sheppard; Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson. Robbins Basic Pathology: With STUDENT CONSULT Online Access. Philadelphia: Saunders. ISBN 1-4160-2973-7.  8th edition.
5. ^ Shariatpanahi, Zahra Vahdat; Taleban, Fourogh Azam, Mokhtari, Majid, Shahbazi, Shaahin (NaN undefined NaN). "Ginger extract reduces delayed gastric emptying and nosocomial pneumonia in adult respiratory distress syndrome patients hospitalized in an intensive care unit". Journal of Critical Care 25 (4): 647–650. doi:10.1016/j.jcrc.2009.12.008. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7590-4YC39P4-8&_user=894227&_coverDate=12%2F31%2F2010&_alid=1667039185&_rdoc=9&_fmt=high&_orig=search&_origin=search&_zone=rslt_list_item&_cdi=12940&_sort=r&_st=4&_docanchor=&_ct=1146&_acct=C000047539&_version=1&_urlVersion=0&_userid=894227&md5=3457ee2d8c4967fb570815fc3b785249&searchtype=a. Retrieved 6 March 2011. 

External links

• Hospital-Acquired, Health Care Associated, and Ventilator-Associated Pneumonia from the Cleveland Clinic
• Cecil Textbook of Medicine