Healthcare associated pneumonia.

Healthcare Associated
Barbara G. Bielska, M.D.
Clarian Arnett Health
Infectious Diseases Department
 HCAP-signs, symptoms and radiographic presence
of PNA in CAP patients with recent contact with the
healthcare system
 HAP- 48-72 hrs after hospital admission
 VAP- 48-72 hrs after endotracheal intubation
Epidemiology of Pneumonia
Leading cause of infectious diseases related death globally
and in the US
CDC (2006) more than 56 K deaths
1.2 mln out of 35 mln annual US hospitalizations
US expenditures > $8 billion annually
300K cases of HAP/y with associated mortality rate 30-70%
HAP lengthens hospital stay by 7-9 days
Healthcare Associated Pneumonia
ATS/IDSA Guidelines 2005
Hospitalization for 2 days or more in the preceding 90 days
Residence in the NH or ECF
Home infusion therapy ( including abx)
Chronic dialysis within 30 days
Home wound care
Family member with a MDR pathogen
HCAP as clinical entity
 Large, heterogeneous patient population with a
poorly defined conglomeration of risk factors that
may increase the risk of infection with a drug
resistant pathogen
HCAP Definitions
by Study
 Kollef at al 2005 ( hospitalization in 30 d, transfer
from other facility, chronic HD)
 Carratala at al 2007 (hospitalization in 90 d, NH
/ECF residence, home infusions/IV therapy,
attended hospital/HD clinic past 30 d, IV
chemotherapy past 30 d)
 Shorr at al 2008 (hospitalization in past 90 d,
NH/ECF, chronic dialysis, immunocompromised
HACP Definitions by Study
 Venditti at al 2009 ( hospitalization/surgery in the
past 180 d, NH/ECF, attended hospital/HD clinic in
the past 30 d, IV chemotherapy in the past 30 d)
 Shindo at al 2009 ( hospitalization in past 90 d,
NH/ECF, home infusions/ IV therapy,
chronic dialysis, home wound care,
The Magnitude of the HCAP Population
CAP vs. HCAP by study
Kollef ’05- CAP-69.2%, HCAP-30.8%
Micek ‘’07 and Shorr’ 08- CAP-32.6%, HCAP- 67.4%
Carratala ’07- CAP-82.7%, HCAP- 17.3%
Venditti’ 09- CAP- 71.2%, HCAP-28.8%
Shindo ’09- CAP- 62%, HCAP- 38%
Avarage CAP-63.9%, HCAP- 36.5%
% HCAP of community dwelling adults hospitalized for
Etiology and Outcomes HCAP vs. CAP
Micek at al ’07single center retrospective cohort analysis (
US) 2003-05
HCAP (n- 431),
CAP (n-208)
S.aureus (% MRSA) 44.5% (68.8), 25.5% (47.1)
S.pneumoniae 10.4%, 40.9%
P.aeruginosa 25.5% , 4.8%
H. influenzae 4.2%, 17.3%
Legionella sp. 0.2%, 3.4%
 HLS not provided, In hospital mortality 24.6% VS. 9.1%
Etiology and Outcomes HCAP vs. CAP
 Venditti at al ’09 multicenter prospective
observational study ( Italy, 55 hosp. ’07)
 HCAP (n-90), CAP (n-49)
 Variable no pathogen data
 HLS in days, mean 18.7 vs. 14.7 , p-value<0.05
 In hospital mortality 17.8% vs. 6.7%, p-value <0.05
Etiology and Outcomes HCAP vs. CAP
Shindo at al ’09 single center retrospective observational
study (Japan), 2005-07
HCAP (n-141),
CAP (n-230)
Pathogen (%, culture positive)
S. pneumoniae -13.5,
S.aureus (% MRSA)- 9.9 (35.7),
6.1 (14.3)
Pseudomonas sp.-5.7,
No pathogen identified- 45.4,
Previous abx past 90 d (%)-63.1,
In hospital mortality %- 21.3,
HCAP or Drug Resistant PNA
 Variables independently associated with resistant
pathogen : MRSA, P.aeruginosa, ESBL Klebsiella
sp /other non fermenting GNR’s,
 Recent hospitalization, 3 mo
 Nursing Home residence/ LTCF, poor functional
 Long term hemodialysis
 ICU admission
 Broad spectrum antibiotics use, 3 mo
Patient’s Risk for Resistant Pathogen
Knowledge of reason for prior admission
 Duration of prior hospitalization
 Receipt of antibiotic therapy
 Known MDR pathogen circulating in community or hospital
 Immunosuppressive disease present or therapy given
 Search for drug resistant pathogen specific risk factor is complicated
by study’s statistical power, selection bias, limitations of case control
study design
 Limited evidence for community dwellers
Difficult, no reliable tools to determine if patient has PNA
No reliable methods to determine causative pathogen when PNA
Sampling methods for ventilator-associated pneumonia: Validation using different histologic and microbiological references. Crit Care Med. 28: 2000; 2799-2804.
New infiltrate on CXR, fever, purulent sputum
other signs of clinical deterioration
Clinical method was shown to be specific for HAP in only 27 of 84
patients in a series reported by Fagon at al.
Evaluation of clinical judgment in the identification and treatment of nosocomial pneumonia in ventilated patients. Chest. 103: 1993; 547-553
Conditions mimicking PNA
in critically ill
Congestive heart failure
Pulmonary embolism
Acute respiratory distress syndrome (ARDS)
Pulmonary hemorrhage
Drug reactions
Imperfect diagnostic tests
Blood cultures, limited role, sensitivity is only 8% to 20%
Sputum neither sensitive, nor specific
Tracheo-bronchial aspirates- high sensitivity, weakness- does not differentiate
between pathogen and colonizer
Hospital-acquired pneumonia: Risk factors, microbiology, and treatment. Chest. 119: 2001; 373S-384S.
BAL, PSB’s do not differ from less invasive tests in terms of sensitivity, specificity
or, more importantly, morbidity and mortality
luck of consensus on the role of invasive diagnostic testing for HAP, subject of
ongoing debate
Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia: Evaluation of outcome. Am J Respir Crit Care Med.
162: 2000; 119-125.
Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia: A randomized trial. Ann Intern Med.
132: 2000; 621-630.
Delay in empiric antibiotics use, worse outcome International conference
for the development of consensus on the diagnosis and treatment of ventilator-associated pneumonia. Chest. 120: 2001; 955-970.
Mortality with prompt abx use 30% vs. 91 % when delayed
Nosocomial pneumonia: A multivariate analysis of risk and prognosis. Chest. 93: 1988; 318-324
Regimens in patients with no known risk factors for MDR
pathogens, and who have early-onset pneumonia (within 5
days of hospitalization) should include coverage for
Enterobacter spp., E. coli, Klebsiella spp., Proteus spp.,
and Serratia marcescens), Haemophilus influenzae and
Streptococcus pneumoniae, MSS. aureus
 ceftriaxone or a quinolone (e.g., ciprofloxacin
or levofloxacin) or ampicillin-sulbactam or
 fluoroquinolone in the empirical regimen of
patients with penicillin allergies
 penicillin skin testing – a mean to decrease
fluoroquinolones use
A pilot study of penicillin skin testing in patients with a history of penicillin allergy admitted to a medical
ICU. Chest. 118: 2000; 1106-1108.
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia * in
Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage †
Antipseudomonal cephalosporin
Cefepime 1-2 g every 8-12 hr
2 g every 8 hr
Imipenem 500 mg every 6 hr or 1 g every 8 hr
1 g every 8 hr
Beta-lactam–beta-lactamase inhibitor
4.5 g every 6 hr
7 mg/kg/day
7 mg/kg/day
Amikacin 20 mg/kg/day
Antipseudomonal quinolones
750 mg/day
400 mg every 8 hr
15 mg/kg every 12 hr
Linezolid 600 mg every 12 hr
Guidelines for the management of adults with hospital-acquired, ventilator-associated, and
healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416.
Duration of treatment
 No consensus, initial low suspicion, no
change in clinical status- dc in 72 hrs
Short-course empiric
antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. A proposed solution for indiscriminate antibiotic
prescription. Am J Respir Crit Care Med. 162: 2000; 505-511.
 Guided by severity, time to clinical response,
and the pathogenic organism
Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare associatedpneumonia. Am J Respir Crit Care Med. 171: 2005; 388-416.
 Treat for at least 72 hours after a clinical
response is achieved
International conference for the development of consensus on the diagnosis and treatment of ventilator-associated
pneumonia. Chest. 120: 2001; 955-970.
Recommendations for Assessing Response to
-Modifications of empirical therapy should be based on results of microbiology testing in
conjunction with clinical parameters.
-Clinical improvement of HCAP usually takes 2 to 3 days and therefore therapy should not be
changed during this period unless there is a rapid clinical decline.
-Narrowing therapy to the most focused regimen possible on the basis of culture data (deescalation of antimicrobials) should be considered for the responding patient.
-The nonresponding patient should be evaluated for possible MDR pathogens, extrapulmonary
sites of infection, complications of pneumonia and its therapy, and mimics of pneumonia.
-Testing should be directed to whichever of these causes is likely after physical examination of
the patient.
Prevention Measures
Based on expert opinion rather than hard data
CDC published a set of 74 recommendations for preventing NAP ,
only 15 strongly supported by well-designed experimental or
epidemiologic studies
14 out of those 15 dealt with surveillance, education, hand washing,
sterilization, proper use of gloves, value of vaccination, and sanitation
Prophylactic antibiotics not be used routinely , only one supported by
well-designed studies
Centers for Disease Control and Prevention. Guidelines for prevention of nosocomial pneumonia. MMWR Morb Mortal Wkly Rep. 46: 1997;
Prevention Measures
Proper hand washing, use of gloves, and measures to reduce
contamination from respiratory therapy equipment
Universally recognized, often not performed, see observational study
performed in an ICU setting 10% of health care workers washed their
hands before having direct patient contact and only 32% washed
their hands after patient contact
Risk factors for an outbreak of multi-drug-resistant Acinetobacter nosocomial pneumonia among intubated patients. Chest. 115: 1999;
Reduction of HCAP Incidence
Reduce immunosuppression, reduce sedation, avoid
transportation of patients out of the ICU, and provide
adequate nutrition
 Oral placement of endotracheal or gastric tubes (sinusitis
 Subglottic secretion drainage, continuous suction of
oropharyngeal secretions in an effort to prevent pooling and
thus aspiration
 Semirecumbent position prevents aspiration of refluxed
gastric contents
Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: A randomised trial. Lancet. 354: 1999;
Reduction of HCAP Incidence
Administration of prophylactic antibiotics or nonabsorbable antibiotics for the purpose
of gastrointestinal decontamination
Not shown to influence mortality or length of stay, use of antibiotics in this manner
may lead to the development of resistant organisms
International conference for the development of consensus on the diagnosis and treatment of ventilator-associated pneumonia. Chest. 120: 2001; 955-970.
Results regarding the role of histamine blockers in the development of HAP are
Antibiotics select out resistant or virulent organisms, 65% of PNA in vented patients
who received prophylactic abx was caused by Acinetobacter and /or Pseudomonas
In antibiotic-naïve patients, only 19% of infections were caused by these pathogens
Nosocomial pneumonia in patients receiving continuous mechanical ventilation. Prospective analysis of 52 episodes with use of a protected specimen brush and
quantitative culture techniques. Am Rev Respir Dis. 139: 1989; 877-884.
Things to Remember
 HACP, HAP, VAP = BAD for the patient
 Quantitative diagnostic microbiology- controversial!
 Cover likely bugs promptly
 Know your local bugs
 De-escalate, shorten duration of therapy
 Specific regimen, combination therapy- no proven
Things to Do
 Get patient’s HOB at 30-45 degrees
 Get the ET tube out
 Get the NG tube out
 Get of the ventilator as ap