Nosocomial Pneumonia

Aka: Nosocomial Pneumonia, Hospital Acquired Pneumonia, Healthcare Associated Pneumonia, HCAP

1. See Also
   1. Pneumonia
   2. Ventilator-Associated Pneumonia
2. Epidemiology
   1. Complicates up to 1% of hospitalizations
   2. Mortality: 30-50%
3. Indications
   1. See Healthcare Associated Multidrug Resistance Risk in Pneumonia (MDR Score)
   2. See Drug Resistance in Pneumonia Score (DRIP Score)
4. Background
   1. As of 2016, IDSA has dropped HCAP designation
      1. HCAP had a broad definition (hospital, Nursing Home, home care in prior 90 days)
      2. Broad definition poorly identified multidrug resistance, and resulted in overuse of broad antibiotics
   2. Designations
      1. Community Acquired Pneumonia (CAP)
      2. Ventilator Associated Pneumonia (VAP)
      3. Hospital Acquired Pneumionia (HAP)
         1. Pneumonia onset within 48-72 hours after hospitalization
         2. Antibiotic coverage broadened to include MRSA
5. Causes
   1. Aspiration following Cerebrovascular Accident (CVA)
      1. Streptococcus Pneumoniae
      2. Anaerobic Bacteria
   2. Mechanical Ventilation
      1. Coliform Bacteria (Gram Negative Bacteria)
      2. Pseudomonas aeruginosa (most common)
      3. Staphylococcus aureus (consider MRSA)
   3. Organ Failure
      1. Coliform Bacteria (Gram Negative Bacteria)
   4. Air Conditioner Contamination
      1. Legionella pneumonia
   5. Airway Obstruction
      1. Anaerobic Bacteria
   6. Corticosteroid use
      1. Yeast
      2. Pneumocystis carinii Pneumonia
   7. Neutropenia (<500 Neutrophils/mm3)
      1. Aspergillus
      2. Candidiasis
6. Symptoms
   1. Fever
   2. Purulent Sputum
7. Labs
   1. Complete Blood Count
      1. Leukocytosis
   2. Arterial Blood Gas
      1. Increased A-a Gradient
8. Imaging: Chest XRay
   1. New or progressive lung infiltrate
9. Management: Empiric Regimen
   1. Antibiotic 1 for MRSA coverage (choose one)
      1. Vancomycin 15-20 mg/kg IV every 8-12 hours (preferred) or
      2. Linezolid 600 mg IV every 12 hours
   2. Antibiotic 2 (choose one)
      1. Cefepime 2 g IV every 12 hours or
      2. Meropenem 1 g every 8 hours or
      3. Piperacillin-Tazobactam (Zosyn) 4.5 g every 6 hours
   3. Additional antibiotics to add to empiric regimen as indicated
      1. Increased local resistance rates
         1. Tobramycin 5-7 mg/kg IV every 24 hours or
         2. Levofloxacin 750 mg IV every 24 hours or
         3. Ciprofloxacin 400 mg IV every 8 hours or
         4. Amikacin 15-20 mg/kg IV every 24 hours
      2. Legionella suspected
         1. Azithromycin 500 mg IV every 24 hours OR
         2. Broad spectrum Fluoroquinolone
            1. Trovafloxacin 300 mg IV q24 hours
            2. Levofloxacin 500 mg IV q24 hours
10. References
    1. Gilbert (2016) Sanford Antimicrobial, accessed IOS app 12/6/2016
    2. Bowton (1999) Chest 115:28S-33S [PubMed]
    3. Cunha (2001) Med Clin North Am 85(1):79-114 [PubMed]
    4. Kollef (1999) Clin Chest Med 20(3):653-70 [PubMed]
    5. Weber (1999) Chest 115:34S-41S [PubMed]