Hospital acquired pneumonia
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Hospital acquired pneumonia

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Nosocomial Pneumonia

Nosocomial Pneumonia

Eliane Haron,M.D.

Nosocomial Pneumonia Epidemiology

 Common hospital-acquired infection  Occurs at a rate of approximately 5-10 cases per

1000 hospital admissions  Incidence increases by 6-20 fold in patients being

ventilated mechanically.  One study suggested that the risk for developing VAP

increases 1% per day  Another study suggested, highest risk occur in the

first 5 days after intubation

Nosocomial Pneumonia

Copyright © 2001 ican, INC. Richards, et al. Crit Care Med. 1999;27:887-892.

Site Distribution in Adult ICUs Major Types of Infection (NNIS data, 1992-1997)

27%

GI

CVS

Other

Pneu

31% 4%

4%

EENT

BSI 19%

5%

6% LRTI 4%

UTI

Urinary tract infections (UTI)

Pneumonia (Pneu)

Primary bloodstream infections (BSI)

Gastrointestinal infections (GI)

Cardiovascular system (CVS)

Eye, ear, nose, and throat infection (EENT)

Lower respiratory infections (LRTI) (other than pneumonia)

OtherN = 14,177

Nosocomial Pneumonia Epidemiology  Nosocomial pneumonia is the leading cause

of death due to hospital acquired infections  Associated with substantial morbidity  Has an associated crude mortality of 30-

50%  Hospital stay increases by 7-9 days per

patient  Estimated cost > 1 billion dollars/year

H os

pi ta

l M or

ta lit

y (%

)

0

10

20

30

40

50

None Early Onset Late Onset

Nosocomial Pneumonia

P = . 504

P<.00 1

P<.001

Mortality and Time of Presentation of HAP

Ibrahim, et al. Chest. 2000;117:1434-1442.

*Upper 95% confidence interval

*

* *

Nosocomial Pneumonia  Hence, the importance of focusing

on:  Accurate diagnosis  Appropriate treatment  Preventive measures

Nosocomial Pneumonia  Pathogenesis  Risk factors  Etiologic agents  Differential diagnosis  Treatment  Prevention

Nosocomial Pneumonia

Pathogenesis

Nosocomial Pneumonia  Microaspiration may occur in up to 45% of

healthy volunteers during sleep  Oropharynx of hospitalized patients is

colonized with GNR in 35-75% of patients depending on the severity and type of underlying illness

 Multiple factors are associated with higher risk of colonization with pathogenic bacteria and higher risk of aspiration

Nosocomial Pneumonia  Pathogenesis

 Invasion of the lower respiratory tract by:  Aspiration of oropharyngeal/GI organisms  Inhalation of aerosols containing bacteria  Hematogenous spread

Colonization Aspiration

HAP

MRSA*

Nosocomial Pneumonia

Risk Factors

Nosocomial Pneumonia  Risk Factors

 Host Factors  Extremes of age, severe acute or chronic

illnesses, immunosupression, coma, alcoholism, malnutrition, COPD, DM

 Factors that enhance colonization of the oropharynx and stomach by pathogenic microorganisms

 admission to an ICU, administration of antibiotics, chronic lung disease, endotracheal intubation, etc.

Nosocomial Pneumonia  Risk Factors

 Conditions favoring aspiration or reflux  Supine position, depressed consciousness, endotracheal

intubation, insertion of nasogastric tube  Mechanical ventilation

 Impaired mucociliary function, injury of mucosa favoring bacterial binding, pooling of secretions in the subglottic area, potential exposure to contaminated respiratory equipment and contact with contaminated or colonized hands of HCWs

 Factors that impede adequate pulmonary toilet  Surgical procedures that involve the head and neck,

being immobilized as a result of trauma or illness, sedation etc.

Nosocomial Pneumonia

Etiologic Agents

Nosocomial Pneumonia  Etiologic Agents

 S.aureus  Enterobacteriaceae  P.aeruginosa  Acinetobacter sp.  Polymicrobial  Anaerobic bacteria  Legionella sp.  Aspergillus sp.  Viral

N os

oc om

ia l P

ne um

on ia

(% )

0

5

10

15

20

25

30

35

40

PA OSSA ORSA ES SM

P = .003

P = .043

P = .408

P = .985 P = .144

Pathoge n

Early-onset NP Late-onset NP

PA = P aeruginosa OSSA = Oxacillin-sensitive

S aureus ORSA = Oxacillin-resistant

S aureus ES = Enterobacter

species SM = S marcescens

Pathogens Associated With HAP

Ibrahim, et al. Chest. 2000;117:1434-1442.

Nosocomial Pneumonia

Diagnosis

Nosocomial Pneumonia  Diagnosis

 Not necessarily easy to accurately diagnose HAP  Criteria frequently include:

 Clinical  fever ; cough with purulent sputum,

 Radiographic  new or progressive infiltrates on CXR,

 Laboratorial  leukocytosis or leukopenia

 Microbiologic  Suggestive gram stain and positive cultures of sputum,

tracheal aspirate, BAL, bronchial brushing, pleural fluid or blood

 Quantitative cultures

Nosocomial Pneumonia  Problems

 All above criteria fairly sensitive, but very non- specific, particularly in mechanically ventilated patients

 Other criteria/problems include  Positive cultures of blood and pleural fluid plus

clinical findings (specific but poor sensitivity)  Rapid cavitation of pulmonary infiltrate absent Tb

or cancer (rare)  Histopathologic examination of lung tissue

(invasive)

Nosocomial pneumonia

 Bronchoscopically Directed Techniques for diagnosis of VAP and Quantitative cultures  Bronchoscopy with BAL/bronchial brushings (10,000

to 100,000 CFU/ml and less than 1% of squamous cells)

 Protected specimen brush method (>10³ CFU/ml)

 Protected BAL with a balloon tipped catheter (>5% of neutrophils or macrophages with intracellular organisms on a Wright-Giemsa stain)

Nosocomial pneumonia

 Multiple studies looked into the accuracy of quantitative culture and microscopic examination of LRT secretions as compared to histopathologic examination and tissue cultures (either lung biopsy or immediate post mortem obtained samples)

 Several trials conclude that use of FOB techniques and quantitative cultures are more accurate

 At least 4 studies concluded that bronchoscopically directed techniques were not more accurate for diagnosis of VAP than clinical and X-ray criteria, combined with cultures of tracheal aspirate

 Therefore no gold standard criteria exist

 CDC- Emerging Infectious Diseases, March-April 2001

Nosocomial Pneumonia  Differential diagnosis

 ARDS  Pulmonary edema  Pulmonary embolism  Atelectasis  Alveolar hemorrhage  Lung contusion

Nosocomial Pneumonia

Treatment

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