HOSPITAL ACQUIRED PNEUMONIA

Allen Widysanto
Introduction
HOSPITAL-ACQUIRED PNEUMONIA
Pneumonia that occurs 48 hours or more after admission, which was not
incubating at the time of admission

VENTILATOR-ASSOCIATED PNEUMONIA
Pneumonia that arises more than 48-72 hours after endotracheal
intubation

HEALTHCARE ASSOCIATED PNEUMONIA (HCAP)

Any patients who was hospitalized in an acute care hospital for two or
more days within 90 days of the infection; resided in a nursing home or
long-term care facility; received recent IV antibiotic therapy,
chemotherapy or wound care within the past 30 days of the current
infection; or attended a hospital or hemodyalisis clinic
Four major principles underlie the
management of
HAP, VAP and HCAP

Avoid untreated or inadequately treated HAP, VAP or

HCAP, because the failure to initiate prompt
appropriate and adequate therapy has been a
consistent factor associated with increased mortality
Recognize the variability of bacteriology from one
hospital to another, spesific sites within the
hospital, and from one time period to another, and
use this information to alter the selection of an
appropriate antibiotic treatment regimen for any
spesific clinical setting
Avoid the overuse of antibiotics by focusing
on accurate diagnosis, tailoring therapy to
the results of lower respiratory tract cultures
and shortening duration of therapy to the
minimal effective period

Apply prevention strategies aimed at

modifiable risk factors
PATHOGENESIS
3 CRITICAL
FACTORS

COLONIZATION OF THE OROPHARYNX WITH

PATHOGENIC ORGANISM

ASPIRATION OF THESE SECRETION FROM

OROPHARYNX INTO THE LOWE R RESPIRATORY TRACT

HOST DEFENSE MECHANISM

How do you diagnose?

New infiltrate or changing

radiographic

Systemic inflammation

Increased purulent secretion

Differential diagnosis

PULMONARY
ARDS
EDEMA

LUNG CONTUSION ATELECTASIS

STRONG
CONFIRMATION CU LT U R E
THERAPY

ANTIBIOTIC THERAPY

Obtain lower respiratory tract culture

Start broad-spectrum empiric antibiotic
therapy
Streamline the regimen to cover only
pathogen present on culture
S T O P antibiotics if culture are negative
S T O P all treatment after 7-8 days
Initial Therapy for Serious
Nosocomial Infection
HAP and sepsis: 2 most common, most serious infections
in ICU, are associated with high mortality rates.
Inadequate therapy for HAP and severe sepsis increases
mortality.
Empiric broad-spectrum therapy must be initiated at the
first suspicion of serious infection to ensure adequate
coverage of all likely pathogens.

Kollef MH. Clin Infect Dis 2000;31(Suppl 4):S131-S138.

Kollef MH. Chest 1999;115:462-474.
Richards MJ et al. Crit Care Med 1999;27:887-892.
Van der Poll T. Lancet Infect Dis 2001;1:165-174.
Bernard GR et al. N Engl J Med 2001;344:699-709.
HAP= hospital-acquired pneumonia
DE-ESCALATION THERAPY

Stage 1
Administer the broadest-spectrum antibiotic
therapy to improve outcomes
(decrease mortality, prevent organ dysfunction, and
decrease hospital length of stay).

Stage 2
Focus on de-escalation as a means to minimize
resistance and improve cost-effectiveness

Trademark of Merck & Co., Inc., Whitehouse Station, NJ.

DE-ESCALATION THERAPY

Stage 1
Administer the broadest-spectrum antibiotic
therapy to improve outcomes
(decrease mortality, prevent organ dysfunction, and decrease
length of hospital stay)

Stage 2
Focus on de-escalation as a means to minimize
resistance and improve cost-effectiveness
What causes treatment failure?

Antibiotic resistance

PRIMER

S E C O N D A RY

Ineffective therapy
Inadequate dosing
Poor penetration to the lung
Anatomic problem (lung abscess/empyema)