32.1-31to2-6 Resident HAP Module

Attending Version
Hospital Acquired Pneumonia (HAP)
Created by Dr. Wendy Gerstein and Dr. David Gonzales, MD
Updated 12/10 by Dr. Gerstein
1) Identify three risk factors for HAP
2) Be able to choose appropriate antibiotic coverage for a penicillin allergic patient.
3) Identify three prevention strategies for HAP.
Healthcare-associated pneumonia in adults: management principles to improve outcomes.
Craven DE; Palladino R; McQuillen DP Infect Dis Clin North Am 2004 Dec;18(4):93962.
Guideline for prevention of nosocomial pneumonia. Centers for Disease Control and
Prevention Respir Care 1994 Dec;39(12):1191-236.
The Role of MRSA in Healthcare-Associated Pneumonia. Lam AP and Wunerlink RG.
Semin Respir Crit Care med 2009; 30:52-60.
Patient is a 75 yo male with a history of Type 2 diabetes, hypertension, and
hypercholesterolemia who is admitted to the hospital with lower extremity DVT of the
left leg. The patient’s health is frail at best and his ambulation has been decreased lately.
The patient lives by himself and was not felt to be a good outpatient candidate for
Lovenox therapy. The patient is admitted for heparin administration with the plan to add
coumadin. During the first few days of hospitalization, the patient was mostly bedbound, only getting up to go to the restroom. Five days after admission, the patient
develops a fever to 39° C with associated sob and cough with purulent sputum. In
addition he feels weaker with decreased appetite. He denies any abdominal complaints or
urinary symptoms.
Diabetes – last hgA1c 8.7%
Lives alone. Widower for 5 yrs.
Retired police officer.
Quit cigarettes 5 yrs ago. Denies alcohol use.
Penicillin – gets a rash
Hydrochlorothiazide 25 mg daily
Metformin 1000 mg po bid
Glypizide 5 mg po bid
Simvastatin 40 mg po daily
Insulin – glargine, nutritional, and ss insulin
Heparin gtt
Hydrochlorothiazide 25 mg
Simvastatin 40 mg
BP 104/54, P 108, RR 24, T 39°, O2 87% RA, 95% on 2 liters
General: Acutely ill-appearing elderly male
HEENT: PERRLA, EOMI, oropharynx- clear; teeth in poor repair
Lungs: scattered crackles RLL, no egophony or dullness noted, otherwise clear
CV: RRR no m/r/g, no JVD, equal dp/radial pulses
Abd: soft, non-tender, + BS
Back: no tenderness with percussion
Ext: no edema or redness, no rashes
Neuro: CN 2-12 grossly intact, motor/strength in 4 extremities grossly intact, oriented x 2
CBC notable for wbc 12.2 k, otherwise wnl
Chem 7 normal except glucose 195 and creatinine 1.
CXR: infiltrate RLL, no associated effusion seen
UA negative
What would be your top three differential diagnoses for the new fever, cough, sob,
hypoxia with infiltrate on CXR?
The most obvious concern is hospital-acquired pneumonia (HAP). Other possibilities
included pulmonary embolus with associated pulmonary infarct, or less likely lung mass
such as malignancy (hypercoagulable state) or lung abscess (poor dentition), or aspiration
pneumonia (bed-bound, frail, elderly).
What pathogens are of concern in HAP?
Resistant GNR’s (Enterobacter, Citrobacter, Klebsiella, E. coli)
Pseudomonas aeruginosa
S. aureus (MRSA)
Anaerobes (aspiration)
Aspergillosis (seen more in prolonged hospitalizations and
immunosuppressed patients)
What would be a reasonable antibiotic regimen for this patient?
Due to type 4 penicillin allergy piperacillin/tazobactam would not be a good choice. For
this patient options include cefepime (good GPC, GNR including pseudomonas
coverage) plus clindamycin (anaerobic coverage plus some MRSA), or levoquin (high
dose) plus clindamycin. It would also be reasonable cover for MRSA with vancomycin if
patient did not respond to initial regimen, if sputum cultures are positive for MRSA, or
patient deteriorates quickly.
Hospital Acquired Pneumonia – outline for discussion
I) Epidemiology and cause
1. It is the second most common nosocomial infection in the US
2. Has high associated morbidity and mortality
3. Increases hospital stay by 7-9 days with increased costs of approximately
$40,000 per patient.
4. Represents 25% of all ICU infections
5. Risk Factors include:
1. Prior antibiotic therapy
2. Current hospitalization > 5 days
3. High frequency of antibiotic resistance in the community
4. Hospitalization for at least 2 days in the preceding 90 days
5. From a nursing home type living situation
6. Recent surgery
7. Chronic dialysis
8. Invasive respiratory devices (intubation, bronchoscopy)
9. Pre-existing pulmonary disease
10. Immunosuppressive disease or therapy
11. Enteral feeding in conjunction with supine position (ICU).
II) Pathogens and antibiotic therapy
1. For patients with no known risk factors for multi-drug resistant (MDR) and early
onset (these patients are rare):
a. Common pathogens
i. Strep pneumoniae, H. influenza, MSSA, gram negative bacilli, E.
coli, Enterobacter spp, proteus spp, S. marcescens
b. Antibiotic choices
i. Extended spectrum flouroquinolones, eg, levofloxacin
ii. Amino-penicillins, eg, ampicillin/sulbactam
iii. 3rd generation cephalosporin, eg, ceftriaxone
iv. Ertapenem
2. For patients with late-onset disease or risk factors for MDR
a. Potential pathogens
i. MDR gram negative bacilli, P. aeruginosa, K. pneumoniae,
Acinetobacter spp, non-MDR gram negative bacilli, MDR gram
positive organisms (MRSA).
ii. In immunosuppressed patients, other potential pathogens include
candida species, aspergillosis, and legionella (associated with
water supply)
b. Initial broad spectrum antibiotic therapy
i. Anti-pseudomonal cephalosporin, eg, cefepime
ii. Anti-pseudomonal carbepenem, eg, imipenem
iii. Anti-pseudomonal penicillin, eg, piperacillin-tazobactam
iv. Anti-pseudomonal flouroquinolones, eg levofloxacin
v. Linezolid or vancomycin if risks factors for MRSA present or
patient very ill.
vi. If patient with signs of sepsis, consider double coverage for
resistant GNRs (can add flouroquinolones or aminoglycoside)
III) Prevention (focusing on non-ICU patients)
1. Strict infection control measures
2. Enteral nutrition preferred over parental nutrition
3. Careful monitoring and limited use and removal of all unnecessary invasive
4. Routine prophylaxis with oral antibiotics is not recommended
5. Limit use of sedative or hypnotic medications that may depress cough or
result in excessive sedation
6. If utilizing PUD therapy, use sucralfate
7. Utilize an insulin protocol for good glucose control in diabetic patients
8. Positioning of patient may be beneficial
Review Questions:
1. Which of the following is NOT a risk factor for HAP?
Nursing home environment
Outpatient dialysis unit
Home IV patient
Group Home
The best answer is D. Group homes (and homeless shelters) have not been associated
with healthcare-associated or hospital-associated infections.
2. True or false questions:
a. MRSA skin colonization is as predictive of invasive infection as nasal
False – Nasal carriage of MRSA is a much higher risk factor for invasive
infection compared to skin colonization.
b. The most predictive risk factor for nosocomial MRSA infection is prior
antibiotic therapy.
True – previous antibiotic use is the major predisposing risk factor for
developing a nosocomial MRSA infection. Fluoroquinolones have been
particularly implicated.
c. Clindamycin, penicillin and flagyl have equivalent efficacy for treating
aspiration pneumonia.
False – clindamycin is the preferred drug. Penicillin has shown higher
failure rates in controlled studies, and flagyl does not adequately cover
microaerophilic and aerobic streptococci in the mouth.
d. It is standard of care to double coverage for gram negative rods when
treating a patient for hospital acquired pneumonia.
False – unless the patient has a documented resistant organism in the
past, or is neutropenic or septic, there is no evidence for "double
i. Post Module Evaluation
Please place completed evaluation in an interdepartmental mail envelope and address to
Dr. Wendy Gerstein, Department of Medicine, VAMC (111).
1) Topic of module:__________________________
2) On a scale of 1-5, how effective was this module for learning this topic? _________
(1= not effective at all, 5 = extremely effective)
3) Were there any obvious errors, confusing data, or omissions? Please list/comment
4) Was the attending involved in the teaching of this module? Yes/no (please circle).
5) Please provide any further comments/feedback about this module, or the inpatient
curriculum in general:
6) Please circle one:
Resident (R2/R3)
Medical student