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ALL / Respiratory Medicine

Hospital-acquired and ventilator-associated pneumonia

Hospital-acquired and ventilator-associated pneumonia

Whilst the majority of patients with pneumonia develop outside of hospital ('community-acquired) it is common for patients to develop significant chest infections whilst admitted. These require special consideration as the causative organisms (and hence recommend antibiotic regimes) are often different.

Definitions
  • hospital-acquired pneumonia (HAP): pneumonia that occurs ≥ 48 hours after admission
  • ventilator-associated pneumonia (VAP): pneumonia that develops ≥48 hours after endotracheal intubation

Common causative organisms
  • Staphylococcus aureus (methicillin-sensitive, MSSA)
  • methicillin-resistant Staphylococcus aureus (MRSA)
  • Pseudomonas aeruginosa - particularly in ventilated patients, most common cause in patients ventilated > 5 days
  • gram-negative bacilli (e.g. Escherichia coli, Klebsiella pneumoniae, Enterobacter spp, Acinetobacter spp) - particularly in late-onset HAP (after 4 days)
  • polymicrobial infections
  • multidrug-resistant (MDR) pathogens

Features
  • clinical findings also seen with community-acquired pneumonia
    • cough
    • sputum
    • dyspnoea
    • fever
    • consolidation/infiltrates on chest x-ray
    • raised white cell count and CRP
  • increased respiratory rate, decreased oxygenation saturations may be seen on observations charts
  • ventilated patients may have
    • decreased tidal volume
    • increased inspiratory pressures
    • decreased oxygenation
  • diagnosis is complicated by the fact that many hospitalised patients will have confounding features due to reason for underlying admission, e.g. dyspnoea or raised CRP

Investigations
  • chest x-ray
  • bloods
    • CRP
    • WBC
  • microbiology
    • peripheral blood cultures
    • lower respiratory tract sample e.g. sputum sample or bronchoalveolar lavage sample
    • should be done prior to the initiation of antibiotics

Management
  • antibiotic choices should of course be guided by microbiology results and local protocols
  • BNF guidance for non-severe signs or symptoms and not at higher risk of resistance
    • oral co-amoxiclav
  • BNF guidance for severe signs or symptoms or at higher risk of resistance
    • IV piperacillin with tazobactam OR IV third-generation cephalosporin ceftazidime OR IV meropenem
    • if MRSA is suspected then add IV vancomycin
+PassMedicine Notes

Whilst the majority of patients with pneumonia develop outside of hospital ('community-acquired) it is common for patients to develop significant chest infections whilst admitted. These require special consideration as the causative organisms (and hence recommend antibiotic regimes) are often different.

Definitions
  • hospital-acquired pneumonia (HAP): pneumonia that occurs ≥ 48 hours after admission
  • ventilator-associated pneumonia (VAP): pneumonia that develops ≥48 hours after endotracheal intubation
Common causative organisms
  • Staphylococcus aureus (methicillin-sensitive, MSSA)
  • methicillin-resistant Staphylococcus aureus (MRSA)
  • Pseudomonas aeruginosa - particularly in ventilated patients, most common cause in patients ventilated > 5 days
  • gram-negative bacilli (e.g. Escherichia coli, Klebsiella pneumoniae, Enterobacter spp, Acinetobacter spp) - particularly in late-onset HAP (after 4 days)
  • polymicrobial infections
  • multidrug-resistant (MDR) pathogens
Features
  • clinical findings also seen with community-acquired pneumonia
    • cough
    • sputum
    • dyspnoea
    • fever
    • consolidation/infiltrates on chest x-ray
    • raised white cell count and CRP
  • increased respiratory rate, decreased oxygenation saturations may be seen on observations charts
  • ventilated patients may have
    • decreased tidal volume
    • increased inspiratory pressures
    • decreased oxygenation
  • diagnosis is complicated by the fact that many hospitalised patients will have confounding features due to reason for underlying admission, e.g. dyspnoea or raised CRP
Investigations
  • chest x-ray
  • bloods
    • CRP
    • WBC
  • microbiology
    • peripheral blood cultures
    • lower respiratory tract sample e.g. sputum sample or bronchoalveolar lavage sample
    • should be done prior to the initiation of antibiotics
Management
  • antibiotic choices should of course be guided by microbiology results and local protocols
  • BNF guidance for non-severe signs or symptoms and not at higher risk of resistance
    • oral co-amoxiclav
  • BNF guidance for severe signs or symptoms or at higher risk of resistance
    • IV piperacillin with tazobactam OR IV third-generation cephalosporin ceftazidime OR IV meropenem
    • if MRSA is suspected then add IV vancomycin


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