Hospital and Ventilator-Acquired Pneumonia

• Learning outcomes include understanding hospital and ventilator-acquired pneumonia, differentiating types of pneumonia, and understanding the treatment algorithm for HAP and VAP.

Hospital and Ventilator-Acquired Pneumonia

• Hospital or nosocomial pneumonia occurs 48 hours or more after admission to the hospital, without signs of incubation at the time of admission.
• Ventilator-acquired pneumonia occurs at least 48 hours after endotracheal intubation.
• HAP patients who are not in the ICU cases are typically less severe than VAP

Risk Factors

• Risk factors include IV antibiotic use within the previous 90 days
• Septic shock
• Acute respiratory disease (ARD) lasting 5 or more days during hospital admission
• Risk factors for multidrug-resistant organisms, Pseudomonas aeruginosa, and other gram-negative bacilli
• Treatment involving agents with over 10% gram-negative resistance
• Unknown antibiotic susceptibility rates in the ICU
• Risk factors for MRSA
• A 10-20% rate of staph resistance to methicillin in the ICU
• Unknown antibiotic susceptibility rates in the ICU

Management of HAP

• If there are no multi-drug resistance (MDR) risk factors or increased mortality risk, one agent against Pseudomonas and MSSA is enough
• Piperacillin-Tazobactam 4.5g IV every 6 hours can be used.
• Cefepime 2g IV every 8 hours is another option.
• Levofloxacin 750 mg daily is available.
• When a patient clinically improves, antibiotics can be taken orally at the same dose as IV.
• Those with risk factors for MDR, Gram-negative bacilli, and MRSA, or increased mortality due to old age and comorbidities, should use two agents against Pseudomonas aeruginosa and other gram-negative bacilli, plus one agent against MRSA.
• Options include Piperacillin-tazobactam, cefepime, imipenem, meropenem, or aztreonam, combined with an aminoglycoside once daily, an antipseudomonal fluoroquinolone, or aztreonam, plus linezolid or vancomycin.
• When considering risk factors just for gram-negative bacilli, combine one of the following (Piperacillin-tazobactam, cefepime, imipenem, meropenem, or aztreonam) with either: Aminoglycoside once daily, antipseudomonal fluoroquinolone, or Aztreonam
• Risk factor just for MRSA, two antibiotics are needed which include one agent against Pseudomonas aeruginosa and other gram-negative bacilli and one MRSA agent.
• Inlcude one of the following (Piperacillin-tazobactam, cefepime, imipenem, meropenem, aztreonam) and one of the following (Linezolide, Vancomycin)

Management of VAP

• Risk factors include IV antibiotic use within 90 days, septic shock at the time of ventilation, and acute respiratory disease (ARD) lasting 5 or more days before VAP.
• Risk factors for MDR, P. aeruginosa, and other gram-negative bacilli
• Treatment with agents with gram-negative resistance in over 10% of cases.
• Unknown antibiotic susceptibility rates in the ICU exist/
• Risk factors for MRSA
• A staph resistance of 10-20% to methicillin in the ICU exist.
• When in doubt, antibiotic susceptibility rates in the ICU are unknown.
• For patients with VAP without known risk factors for MDR, one agent against Pseudomonas aeruginosa, other gram-negative bacilli, and MSSA will suffice.
• Patients with VAP and known risk factors for MDR needs 2 agents against P. aeruginosa, other gram-negative bacilli, and one MRSA agent.
• Patients with VAP and known MDR risk factors for gram-negative bacilli should receive 2 agents against P. aeruginosa.
• Patients with VAP and MRSA risk factors should get one agent against P. aeruginosa and other gram-negative bacilli and one MRSA agent.
• HAP or VAP therapy lasts 7 days

Aspiration Pneumonia

• It comes from the inhalation of oropharyngeal or gastric content into the lower airways.
• Aspiration pneumonia is caused by bacteria in the oral and nasal pharynx.
• Management includes immediate tracheal suction to clear fluid and particulate matter causing obstruction.
• For anaerobic bacteria, use sulbactam/ampicillin 1.5-3gm IV every 6 hours or amoxicillin/clavulanic acid 1gm or 2gm for normal renal function.
• Use current quinolone empiric therapy with stress-dose steroids for patients who remain hypotensive despite fluids and vasopressors.

Viral Pneumonia

• Non-pharmacologic treatment includes oxygen for dyspnea, fluids for dehydration, and mechanical ventilation if respiratory function is present or impaired.
• Pharmacologic management includes a Beta 2-agonist for bronchospasm and respiratory isolation antibiotics if there is infiltrate in chest x-ray.
• Antiviral therapy
• Acyclovir should be considered if varicella or herpes is suspected.
• For influenza, use Oseltamivir or Zanamivir.
• If there is RSV, parainfluenza, measles, or adenovirus use Ribavirin.
• Gancyclovir, foscarnet should be used if CMV is suspected

Prevention of Pneumonia

• Some tips inlcude: avoid smoking, good hygiene, washing hands, and coughing or sneezing into the elbow.
• Vaccination
• Use the Pneumococcal vaccine (prevnar) against strept pneumonia
• Hib vaccine # Haemophilus influenza type B
• Consider palivizumab or RSV vaccine #children 24 month to prevent pneumonia # RSV