Pneumonia nosocomiala

= pneumonia de spital, dobindita ca

urmare a spitalizarii, “hospital-
acquired pneumonia”
 Pneumonia nosocomiala2
• = pneumonia ce apare la mai mult de 48 ore de la
internare, cu excluderea oricarei infectii care era in
perioada de incubare in momentul internarii
• 5-10 cazuri/1000 internari, de 6-20 de ori mai mult
la bolnavii ventilati mecanic
• a doua cauza de infectie nosocomiala in SUA
• creste durata spitalizarii in medie cu 7-9
zile/pacient
 Pneumonia nosocomiala3
• Mortalitate de pina la 70%, dar nu intregime
atribuabila infectiei!
• Insa! - mortalitatea atribuabila infectiei
creste cind exista bacteriemie sau cind
agentul etiologic este Pseudomonas
aeruginosa sau Acinetobacter
 Pneumonia nosocomiala4
Tratamentul se bazeaza de:
1. evaluarea severitatii bolii
2. prezenta de factori de risc pentru un anume
microb
3. momentul aparitiei si tratamentele
anterioare (ex: infectia cu microbi meticilino-rezistenti
este mai probabila daca bolnavul a primit antibiotice
inaintea debutului pneumoniei)
 PN- tratamentul antibiotic
• Tratamentul initial este, prin necesitate,
empiric!
• Monoterapie sau combinatii de antibiotice?
• Ce mecanism bactericid?
• Ce concentratii pulmonare?
• Cit timp?
 Pneumonia nosocomiala: concluzii

Many patients with presumed nosocomial

pneumonia probably have infiltrates on the chest
radiograph, fever, and leukocytosis resulting from
noninfectious causes. Because of the high mortality
and morbidity associated with nosocomial
pneumonias, however, most clinicians treat such
patients with a 2-week empiric trial of antibiotics.
Cunha BA, Med Clin North Am 2001; 85: 79-114
 Pneumonia nosocomiala: concluzii

Before therapy is initiated, the clinician should rule out other causes of
pulmonary infiltrates, fever, and leukocytosis that mimic a nosocomial
pneumonia (e.g., pre-existing interstitial lung disease, primary or metastatic lung
carcinomas, pulmonary emboli, pulmonary drug reactions, pulmonary
hemorrhage, collagen vascular disease affecting the lungs, or congestive heart
failure).
If these disorders can be eliminated from diagnostic consideration, a 2-week trial
of empiric monotherapy is indicated.
The clinician should treat cases of presumed nosocomial pneumonia as if P.
aeruginosa were the pathogen.
Although P. aeruginosa is not the most common cause of nosocomial pneumonia,
it is the most virulent pulmonary pathogen associated with nosocomial
pneumonia. Coverage directed against P. aeruginosa is effective against all other
aerobic gram-negative bacillary pathogens causing hospital-acquired pneumonia.
The clinician should select an antibiotic for empiric monotherapy that is highly
effective against P. aeruginosa, has a good side-effect profile, has a low resistance
potential, and is relatively inexpensive in terms of its cost to the institution.
Cunha BA, Med Clin North Am 2001; 85: 79-114
• patients who are not intubated and
mechanically ventilated should be managed
like patients with VAP, using the same
approach to identify risk factors for
infection with specific pathogens.
• early, appropriate antibiotics in adequate
doses, while avoiding excessive antibiotics
by de-escalation of initial antibiotic therapy,
based on micro- biologic cultures and the
clinical response of the patient, and
shortening the duration of therapy to the
minimum effective period.
• variability of bacteriology from one hospital
to another and from one time period to an-
other and recommends taking local
microbiologic data into ac- count when
adapting treatment recommendations to any
specific clinical setting
• The initial, empiric antibiotic therapy algorithm
includes two groups of patients: one with no need
for broad- spectrum therapy, because these
patients have early-onset HAP, VAP, or HCAP
and no risk factors for MDR pathogens, and a
second group that requires broad-spectrum
therapy, because of late-onset pneumonia or
other risk factors for infection with MDR
pathogens.
• The initial, empiric antibiotic therapy algorithm
includes two groups of patients: one with no need
for broad- spectrum therapy, because these
patients have early-onset HAP, VAP, or HCAP
and no risk factors for MDR pathogens, and a
second group that requires broad-spectrum
therapy, because of late-onset pneumonia or
other risk factors for infection with MDR
pathogens.
 key recommendations and
principles :
• • A lower respiratory tract culture needs to
be collected from all patients before
antibiotic therapy, but collection of cultures
should not delay the initiation of therapy in
critically ill patients.
• Negative lower respiratory tract cultures
can be used to stop antibiotic therapy in a
patient who has had cultures obtained in the
absence of an antibiotic change in the past
72 hours.
• Early, appropriate, broad-spectrum,
antibiotic therapy should be prescribed with
adequate doses to optimize anti- microbial
efficacy.
• An empiric therapy regimen should include
agents that are from a different antibiotic
class than the patient has re- cently
received.
• Combination therapy for a specific pathogen should be used judiciously in the therapy of HAP, and consideration
should be given to short-duration (5 days) aminoglycoside therapy, when used in combination with a -lactam to treat
P. aeruginosa pneumonia.
• Linezolid is an alternative to vancomycin, and uncon- firmed, preliminary data suggest it may have an advantage for
proven VAP due to methicillin-resistant S. aureus.
• Colistin should be considered as therapy for patients with VAP due to a carbapenem-resistant Acinetobacter species.
• Aerosolized antibiotics may have value as adjunctive ther- apy in patients with VAP due to some MDR pathogens.
• De-escalationofantibioticsshouldbeconsideredoncedata are available on the results of lower respiratory tract cul- tures
and the patient’s clinical response.
• A shorter duration of antibiotic therapy (7 to 8 days) is recommended for patients with uncomplicated HAP, VAP, or
HCAP who have received initially appropriate therapy and have had a good clinical response, with no evidence of

infection with nonfermenting gram-negative bacilli .