HCAP & HAP
Pamela Charity, MD
Cathryn Caton, MD, MS
OBJECTIVES

Define pneumonia

Define HAP and review the characteristics

Define HCAP

Diagnosing HCAP and HAP

Treatment of HCAP and HAP

Review treatment algorithm
KEY MESSAGES

Be familiar with the following:





Definition of both terms
Start antibiotics within 4 hours of making the
diagnosis
Know which antibiotics to start empirically
Know where to access the antibiogram
Know how and when to de-escalate antibiotic therapy
PNEUMONIA
Fever
 Leukocytosis
 Infiltrate on CXR

HOSPITAL ACQUIRED PNEUMONIA


Category of pneumonia that occurs 48 hours or
more after admission
Encompasses

healthcare associated pneumonia and

ventilator associated pneumonia
HOSPITAL ACQUIRED PNEUMONIA

Time of onset

Is an epidemiologic variable and

Risk factor for specific pathogens and

Affects outcomes
HOSPITAL ACQUIRED PNEUMONIA

Early onset
Within first 4 days
 Better prognosis
 More likely to be caused by antibiotic-sensitive
bacteria


Above is true unless patient
Received prior antibiotics
 Have had prior hospitalization within 90 days


Greater risk for colonization and infection with MDR
pathogens
HOSPITAL ACQUIRED PNEUMONIA

Late onset

5 days or more

More likely to be caused by MDR pathogens


risk factors for MDR
 Antimicrobial therapy in preceding 90 days
 Presence of risk factors for HCAP
 Immunosuppresive disease/therapy
Increased morbidity and mortality
HEALTHCARE ASSOCIATED PNEUMONIA

Category of pneumonia in patients with recent
close contact with the health care system

Hospitalized for 2 or more days within last 90 days

Resides in nursing home or long-term care facility

Received recent IV antibiotic therapy, chemotherapy,
or wound care within past 30 days

Hemodialysis
MAKING THE DIAGNOSIS

History – this will determine the classification of
pneumonia

Physical exam findings

Laboratory data

Radiographic findings
Antibiotics should be initiated within 4 hours of
making the diagnosis.
CHOOSING EMPIRIC ANTIBIOTICS
HCAP and HAP are treated similarly
 Think about multi-drug resistant pathogens


Gram Neg
Pseudomona Aeruginosa – some are only sensitive to
polymyxin B
 Serratia Marcescens
 Klebsiella
 Enterobacter
 Acinetobacter


Gram Positive
MRSA
 VRE

CHOOSING EMPIRIC ANTIBIOTICS
DE-ESCALATION OF ANTIBIOTIC THERAPY

This may be appropriate if
Clinical improvement at 48-72 hours
 Cultures are positive
 Treat for 7-8 days and reassess patient
 Single agent such as moxifloxacin may be
appropriate


May stop antibiotics if clinical improvement at
48-72 hours and cultures are negative
TREATMENT ALGORITHM
REFERENCES
ATS/IDSA Guidelines
Am J Respir Crit Care Med Vol 171. pp 388-416,
2005