Healthcare Associated Healthcare Associated PneumoniaPneumonia

State Of Evidence To DateState Of Evidence To Date

Guide – Dr N T MinzGuide – Dr N T MinzPresenter – Swayang Sudha PandaPresenter – Swayang Sudha Panda

Department of MedicineDepartment of Medicine

CLASSIFICATIONCLASSIFICATION Pneumonia is an infection of pulmonary parenchymaPneumonia is an infection of pulmonary parenchyma Traditionally pneumonia was classified as Traditionally pneumonia was classified as

CAP VAPCAP VAP HAPHAP CAP – Community Acquired PneumoniaCAP – Community Acquired Pneumonia HAP – Hospital Acquired PneumoniaHAP – Hospital Acquired Pneumonia VAP – Ventilator Associated PneumoniaVAP – Ventilator Associated Pneumonia

However some patients presenting as outpatients with onset of Pneumonia have been found to be infected with Multi Drug Resistant (MDR) pathogens previously associated with HAP

The potential involvement of of the MDR pathogens has led to a new category of pneumonia term as Health Care Associated Pneumonia (HCAP)

Definitions Definitions

Community acquired pneumonia (CAP)Community acquired pneumonia (CAP)

Etiology - Etiology -

Outpatient Hospitalised patientNon ICU ICU

Streptococcus pneumoniae

Streptococcus pneumoniea Streptococcus pneumoniea

Mycoplasma pneumoniae

Mycoplasma pneumoniae Staphylococcus aureus

Haemophilus influenzae

Chlamydia pneumoniae Legionella spp

Chlamydia pneumoniae

Haemophilus influenzae Gram negative bacilli

Respiratory virus Legionella spp.Respiratory virus

Haemophilus influenzae

Treatment of CAP Treatment of CAP Outpatient Outpatient 1)1) Previously healthy and no abx in past three months :- macrolide or Previously healthy and no abx in past three months :- macrolide or

doxycyclinedoxycycline2)2) Co morbidities or abx in past 3 months :-Co morbidities or abx in past 3 months :- fluoroquinolone or beta lactam /cephalosporin +macrolidefluoroquinolone or beta lactam /cephalosporin +macrolide Inpatient ,non ICUInpatient ,non ICU FluoroquinnoloneFluoroquinnolone beta lactam /cephalosporin +macrolidebeta lactam /cephalosporin +macrolide Inpatient , ICUInpatient , ICU beta lactam +beta lactam + azithromycin or fluoroquinoloneazithromycin or fluoroquinolone If pseudomonas thenIf pseudomonas then anti pseudomonal betea lactamanti pseudomonal betea lactamBeta lactam +aminoglycosideBeta lactam +aminoglycosideBetalactam+aminoglycoside+anti pseudomonal flourquinoloneBetalactam+aminoglycoside+anti pseudomonal flourquinolone If CA-MRSAIf CA-MRSALinezolide or vancomycinLinezolide or vancomycin

Ventilator associated pneumonia (VAP) Ventilator associated pneumonia (VAP)

EtiologyEtiologyNon MDR pathogens MDR pathogens

Streptococcus pneumoniae P aeruginosa

Other streptococcus spp. MRSA

H. influenzae Acinatobacter spp.

MSSA Antibiotic resistant enterobacteriaceae

Antibiotic sensitive enterobateriaceae

Enterobacter spp.

E coli ESBL positive strains

K pneumoniae Klebseilla spp

Proteus spp. Legionella pneumoniae

Enterobacter spp. Burkholderia cepacia

Serratia marcescens Aspergillus spp

Hospital accquired pneumonia (HAP)Hospital accquired pneumonia (HAP)

The etiology of HAP (inside and out side ICU) is similar The etiology of HAP (inside and out side ICU) is similar to VAP except for the fact that there is higher to VAP except for the fact that there is higher prevalence of non MDR pathogens and the underlying prevalence of non MDR pathogens and the underlying host immunity is better in non intubated patient. host immunity is better in non intubated patient.

Only pathogens more common in non VAP population Only pathogens more common in non VAP population are anaerobes because of the greater risk of aspiration are anaerobes because of the greater risk of aspiration in non intubated patient and low oxygen tension in the in non intubated patient and low oxygen tension in the respiratory tract of these patient respiratory tract of these patient

Treatment for VAP/HAPTreatment for VAP/HAP Patient without risk for MDR pathogensPatient without risk for MDR pathogensCeftriaxone or Ceftriaxone or Moxi/cipro/levo- floxacin orMoxi/cipro/levo- floxacin orAmpicillin/sulbactam orAmpicillin/sulbactam orErtapenemErtapenem Patient with risk factor for MDRPatient with risk factor for MDRBeta lactam (ceftazidime or cefipime or P/T, meropenem or imipenemBeta lactam (ceftazidime or cefipime or P/T, meropenem or imipenemAminoglycoside active against gram negetive bacterial pathogenAminoglycoside active against gram negetive bacterial pathogen (gentamycin/tobramycin) or(gentamycin/tobramycin) or Levofloxacin/ciproflxacinLevofloxacin/ciproflxacinAgent active gram positive bacterial pathogenAgent active gram positive bacterial pathogen linezolidelinezolide vancomycinvancomycin

THE LOWER FREQUENCY OF MDR PATHOGEN IN HAP ALLOWS FOR TREATMENT WITH THE LOWER FREQUENCY OF MDR PATHOGEN IN HAP ALLOWS FOR TREATMENT WITH MONOTHERAPYMONOTHERAPY

Concept of HCAPConcept of HCAP

HCAP represents the subgroup of patients with HCAP represents the subgroup of patients with ongoing contact with healthcare which places them ongoing contact with healthcare which places them at increased risk of infection with potentially at increased risk of infection with potentially resistant pathogen like resistant pathogen like Pseudomonas aeruginosa and and Methicillin resistant Staph. aureus

HCAP bridges what was thought to be a clear HCAP bridges what was thought to be a clear divide between CAP and HAPdivide between CAP and HAP

Definition of Healthcare Associated PneumoniaDefinition of Healthcare Associated PneumoniaATS/IDSA Guidelines 2005ATS/IDSA Guidelines 2005

HCAP is defined based on the presence of one of the HCAP is defined based on the presence of one of the following risk factors following risk factors

Hospitalization for 2 days or more in the preceding 90 daysHospitalization for 2 days or more in the preceding 90 days Residence in the Nursing Home or Extended Care FacilityResidence in the Nursing Home or Extended Care Facility Home infusion therapy ( including antibiotics)Home infusion therapy ( including antibiotics) Chronic dialysis within 30 daysChronic dialysis within 30 days Home wound careHome wound care Family member with a MDR pathogenFamily member with a MDR pathogen

Why patients with HCAP are at an Why patients with HCAP are at an increased risk ?increased risk ?

Due to infection with potentially resistant organismsDue to infection with potentially resistant organisms

Due to failure to appreciate shifting pattern in Due to failure to appreciate shifting pattern in epidemiology the patient receive empirical epidemiology the patient receive empirical antibiotics which are not active against culprit antibiotics which are not active against culprit pathogenspathogens

Aetiolgy of HCAPAetiolgy of HCAPCONDITION MRSA Pseudomonas

aeruginosaAcinetobacter spp

MDREnterobacteriaceae

Hospitalization for >=48 hr Y Y Y Y

Hospitalization for >=2 days in prior 3 months

Y Y Y Y

Nursing Home or Extended Care Facility residence

Y Y Y Y

Antibiotic Tx in preceeding 3 months

Y Y

Chronic dialysis Y

Home infusion thrapy Y

Home wound care Y

Family member with MDR infection

Y Y

Etiology of HCAP – more similar to Etiology of HCAP – more similar to HAP than CAPHAP than CAP

There is high variability in the etiology of HCAP There is high variability in the etiology of HCAP according to the sub group of patientaccording to the sub group of patient

There is also high prevalence of MDR organisms in There is also high prevalence of MDR organisms in patient with HCAPpatient with HCAP

So this calls for an antibiotic therapy with a very broad So this calls for an antibiotic therapy with a very broad spectrum so as to cover the variety of pathogens in spectrum so as to cover the variety of pathogens in patients presenting with HCAP and also to keep in patients presenting with HCAP and also to keep in mind the problem of MDR pathogensmind the problem of MDR pathogens

Debate regarding the concept of HCAPDebate regarding the concept of HCAP

The empirical therapy for HCAP has a very broad The empirical therapy for HCAP has a very broad scectrumscectrum

The potential size of the population pathogens causing The potential size of the population pathogens causing HCAP was hugeHCAP was huge

Variable ability of the physicians to narrow the Variable ability of the physicians to narrow the spectrum of therapy based on culture studiesspectrum of therapy based on culture studies

ALL THESE POINTS QUESTION THE ABILITY OF THE CRITERIA OF ALL THESE POINTS QUESTION THE ABILITY OF THE CRITERIA OF HCAP HCAP TO CORRECTLY TO CORRECTLY IDENTIFY PATIENT WITH POTENTIALLY RESISTANT ORGANISMIDENTIFY PATIENT WITH POTENTIALLY RESISTANT ORGANISM

Studies On HCAPStudies On HCAP So various studies have been done to understand the So various studies have been done to understand the

complexities of the clinical entity HCAPcomplexities of the clinical entity HCAP Eight studies have described the epidemiology and outcomes Eight studies have described the epidemiology and outcomes

of HCAP and CAP. Out of these 6 were retrospective and 2 of HCAP and CAP. Out of these 6 were retrospective and 2 were prospective.6 were single centre and 2 were multi were prospective.6 were single centre and 2 were multi centre. All were performed between 2005 to 2010 with data centre. All were performed between 2005 to 2010 with data collection between 2001 to 2010 . 4 required isolation of a collection between 2001 to 2010 . 4 required isolation of a pathogen (i.e culture positivity ) as an inclusion criteria while pathogen (i.e culture positivity ) as an inclusion criteria while the rest enrolled patients meeting clinical and radiological the rest enrolled patients meeting clinical and radiological criteria for pneumonia regardless of culture findingcriteria for pneumonia regardless of culture finding

Author geography centers Design Culture total

Kollef et al USA Multi RC y 4543

Micek et al USA single RC y 639

Carratala et al Spain single PC n 727

Shindo et al Japan single RC y 371

Venditti et al Italy multi PC n 362

Schieber et al USA single RS y 190

Seki et al Japan single RS y 34

Park et al Korea single RS y 345

Each study applied a set of risk factors adapted Each study applied a set of risk factors adapted from ATS/IDSA and recent hospitalization as the from ATS/IDSA and recent hospitalization as the most consistently used criteriamost consistently used criteria

All studies utilized various measures to assess the All studies utilized various measures to assess the illness severity including Pneumonia Severity Index illness severity including Pneumonia Severity Index (PSI), a modification of CURB-65 and the need for (PSI), a modification of CURB-65 and the need for mechanical ventilationmechanical ventilation

The graph shows higher incedence of MRSA and Pseudomonas aeruginosa in HCAP

This graph shows the proportion of patient receiving in appropriate antibiotic therapy in each case

Inferences from the studiesInferences from the studies

MRSA and Pseudomonas aeruginosa are most MRSA and Pseudomonas aeruginosa are most common in HCAP. And as there is variation common in HCAP. And as there is variation between the prevalence of the pathogens in both between the prevalence of the pathogens in both the groups so is the variation between the severity the groups so is the variation between the severity the diseasesthe diseases

the need for mechanical ventilation varied between the need for mechanical ventilation varied between 3.2% to 100% in HCAP and 4.7% to 100% in CAP3.2% to 100% in HCAP and 4.7% to 100% in CAP

The risk of receiving inappropriate antibiotic therapy The risk of receiving inappropriate antibiotic therapy was higher in HCAP than in CAP was higher in HCAP than in CAP

There is relative prolongation of hospital stay in HCAP There is relative prolongation of hospital stay in HCAP as compared to CAPas compared to CAP

The crude mortality in HCAP was higher in comparison The crude mortality in HCAP was higher in comparison to CAPto CAP

So the conclusion being HCAP is a separate entity So the conclusion being HCAP is a separate entity from CAP with higher severity of illness, higher risk of from CAP with higher severity of illness, higher risk of infection with MDR pathogen and is associated with infection with MDR pathogen and is associated with higher risk of being treated with an inappropriate higher risk of being treated with an inappropriate antibiotic therapy hence is associated with 2 fold higher antibiotic therapy hence is associated with 2 fold higher mortalitymortality

On going controversies On going controversies

How well does the definition of Healthcare How well does the definition of Healthcare associated pneumonia perform?associated pneumonia perform?

The studies have shown that the crieteria of HCAP The studies have shown that the crieteria of HCAP underperforms in this vein with a sensitivity of underperforms in this vein with a sensitivity of 78.3% and a specificity of 56.2%78.3% and a specificity of 56.2%

The studies also sought to devlop an appropriate The studies also sought to devlop an appropriate tool for screening of HCAP and developed a scoring tool for screening of HCAP and developed a scoring system based on 3 criteriassystem based on 3 criterias

1.1. Immunosupression (3 points)Immunosupression (3 points)2.2. Admission from long term care (2 points)Admission from long term care (2 points)3.3. Recent antibiotic exposure (1 point)Recent antibiotic exposure (1 point)A total of 6 pointsA total of 6 points Testing this score and its ability to detect patients with infection Testing this score and its ability to detect patients with infection

revealed that a direct relationship between the score and revealed that a direct relationship between the score and frequency of infection with MRSA, Pseudomonas aeruginosa and frequency of infection with MRSA, Pseudomonas aeruginosa and pathogens producing extended spectrum Beta Lactamases. The pathogens producing extended spectrum Beta Lactamases. The risk of infection with an resistant organisms was 40% in patient risk of infection with an resistant organisms was 40% in patient with a score >2 with a score >2

This signifies the need of development of better diagnostic tool to This signifies the need of development of better diagnostic tool to stratify patient presenting with pneumonia stratify patient presenting with pneumonia

The problem of culture positivityThe problem of culture positivity Since the rate of culture positivity Is generally less Since the rate of culture positivity Is generally less

than 50% the use of HCAP as a concept will lead to than 50% the use of HCAP as a concept will lead to overuse of broad spectrum antibiotics and add to the overuse of broad spectrum antibiotics and add to the problem of microbial resistance.problem of microbial resistance.

Reassuringly the studies have found that despite Reassuringly the studies have found that despite higher prevalence of treatment concordant for CAP in higher prevalence of treatment concordant for CAP in patient with culture negative HCAP the mortality was patient with culture negative HCAP the mortality was not much high in this group in comparision to the not much high in this group in comparision to the culture positive HCAP culture positive HCAP

Since to date there is no reliable way to determine Since to date there is no reliable way to determine at the outset of treatment which patient will be at the outset of treatment which patient will be culture positive and which patient will be culture culture positive and which patient will be culture negative it appears prudent to apply HCAP negative it appears prudent to apply HCAP definition to rapidly identify patient with resistant definition to rapidly identify patient with resistant organism and begin treatment for HCAP.organism and begin treatment for HCAP.

Then this should be followed by an effort to Then this should be followed by an effort to deescalate the initial therapy in response to the deescalate the initial therapy in response to the culture resultsculture results

It has been observed in the studies that treating a It has been observed in the studies that treating a patient eventually classified as culture negative patient eventually classified as culture negative HCAP according to CAP guideline does not HCAP according to CAP guideline does not necessarily harm the patientnecessarily harm the patient

Thus a broad spectrum regimen for HCAP should Thus a broad spectrum regimen for HCAP should be started and by day 3 if no microbiologic data be started and by day 3 if no microbiologic data exists to facilitate de-escalation the antibiotic exists to facilitate de-escalation the antibiotic regimen might be narrowed down to a CAP like regimen might be narrowed down to a CAP like regimen with a narrower spectrum regimen with a narrower spectrum

Guideline concordant treatmentGuideline concordant treatment The studies have shown though 79% of the patient The studies have shown though 79% of the patient

admitted under CAP were treated with guideline admitted under CAP were treated with guideline concordant regimen only 9% of the patient admitted concordant regimen only 9% of the patient admitted under HCAP were treated with guideline concordant under HCAP were treated with guideline concordant regimen despite the 71% of the participants being regimen despite the 71% of the participants being familiar with and in agreement with the HCAP familiar with and in agreement with the HCAP guidelines guidelines

But the assessment of the relationship between guideline But the assessment of the relationship between guideline discordant treatment and outcomes on a group of patients discordant treatment and outcomes on a group of patients from nursing home care facility with pneumonia has shown from nursing home care facility with pneumonia has shown that there is not much difference patients being treated with that there is not much difference patients being treated with HCAP vs. CAP algorithmHCAP vs. CAP algorithm

But again this might be due to But again this might be due to 1. culture negative HCAP which might be treated 1. culture negative HCAP which might be treated

successfully by CAP regimen orsuccessfully by CAP regimen or 2. the local prevalence of resistant organism being low 2. the local prevalence of resistant organism being low

obviated the need for an anti biotic with broader spectrumobviated the need for an anti biotic with broader spectrum

DiagnosisDiagnosis

• Pneumonia should be suspected in patients with a new or Pneumonia should be suspected in patients with a new or progressive infiltrate on lung imaging and clinical characteristics progressive infiltrate on lung imaging and clinical characteristics such as:such as:

•FeverFever

•Purulent sputumPurulent sputum

•LeukocytosisLeukocytosis

•Decline in oxygenationDecline in oxygenation

•Radiographic findings plus two of the clinicalRadiographic findings plus two of the clinical findings.findings.

•69% sensitivity and 75% specificity for pneumonia.69% sensitivity and 75% specificity for pneumonia.

DiagnosisDiagnosis•Comprehensive medical history and examinationComprehensive medical history and examination

•Gram staining and culture of sputum – main purpose of gram Gram staining and culture of sputum – main purpose of gram stain is to ensure that the sample is suitable for culture. To be stain is to ensure that the sample is suitable for culture. To be adequate for culture a sputum sample should contain >25 adequate for culture a sputum sample should contain >25 neutrophils and <10 squamous cell. For patient admitted to the neutrophils and <10 squamous cell. For patient admitted to the ICU a deep suction aspirate or a broncho-alveolar lavage ICU a deep suction aspirate or a broncho-alveolar lavage sample may give an high yeild in culture sample may give an high yeild in culture

•Blood culture – though the yeild is low it should be collected Blood culture – though the yeild is low it should be collected before the initiation of the antibiotic therapybefore the initiation of the antibiotic therapy

•Antigen tests - to exclude Pneumococci and Antigen tests - to exclude Pneumococci and legionella speices legionella speices

•Serology – this my aid to exclude atypical Serology – this my aid to exclude atypical antigen like Mycoplasma, Coxiella,legionellaantigen like Mycoplasma, Coxiella,legionella

•Polymerase chain reactionPolymerase chain reaction

• Chest x-ray (preferably PA and Lat) to identify Chest x-ray (preferably PA and Lat) to identify infiltrate and possible complication such infiltrate and possible complication such as effusion or cavitationsas effusion or cavitations•Arterial oxygenation saturation +/- ABGArterial oxygenation saturation +/- ABG

•A lower respiratory tract culture needs to be A lower respiratory tract culture needs to be collected from all patients before antibiotic collected from all patients before antibiotic therapy, but collection of cultures should not therapy, but collection of cultures should not delay the initiation of therapy in critical ill delay the initiation of therapy in critical ill patients.patients.

•semi quantitative or quantitative culture data semi quantitative or quantitative culture data can be used for management of patients with can be used for management of patients with HCAPHCAP

DiagnosisDiagnosis

•Quantitative cultures increase specificity of the Quantitative cultures increase specificity of the diagnosis diagnosis

•Negative lower respiratory tract cultures can be Negative lower respiratory tract cultures can be used to change antibiotic therapy in a patient to used to change antibiotic therapy in a patient to a CAP like regimena CAP like regimen

When to suspect Risk for Resistant PathogenWhen to suspect Risk for Resistant Pathogen

Knowledge of prior admissionKnowledge of prior admission Receipt of antibiotic therapyReceipt of antibiotic therapy Known MDR pathogen circulating in community or hospitalKnown MDR pathogen circulating in community or hospital Immunosuppressive disease present or therapy givenImmunosuppressive disease present or therapy given

Assesing the severity and requirement Assesing the severity and requirement of hospital admissionof hospital admission

Can be done by Can be done by 1.1. CURB 65CURB 652.2. PSIPSI3.3. ATS guidelinesATS guidelines

CURB 65CURB 65 C – ConfusionC – Confusion U - Blood Urea Nitrogen >19mg/dl or 7mmol/lU - Blood Urea Nitrogen >19mg/dl or 7mmol/l R - Respiratory rate >= 30R - Respiratory rate >= 30 B - SBP < 90 mm of Hg or DBP < 60 mm of HgB - SBP < 90 mm of Hg or DBP < 60 mm of Hg Age >= 65 yrsAge >= 65 yrs for each point the score is 1for each point the score is 1 Score Group Mortality Management

0-1 1 1.5% Out patient

2 2 9.2% Brief inpatient

3-5 3 22% ICU

ATS criteriaATS criteria MINOR MINOR 1)1) RR >30RR >302)2) PaO2/FiO2 ratio < 250PaO2/FiO2 ratio < 2503)3) Multilobar radiographic in volvementMultilobar radiographic in volvement4)4) Uremia (BUN >20 mg/dl)Uremia (BUN >20 mg/dl)5)5) Leucopenia (WBC count < 4000/dl)Leucopenia (WBC count < 4000/dl)6)6) Thrombocytopenia (Plt count < 1 lakh/dl)Thrombocytopenia (Plt count < 1 lakh/dl)7)7) Hypothermia (core temperature < 35 degree C)Hypothermia (core temperature < 35 degree C)8)8) Hypotension requiring aggressive fluid resuscitationHypotension requiring aggressive fluid resuscitation

MAJORMAJOR1)Invasive mechanical ventilation1)Invasive mechanical ventilation2)Septic shock with need for vassopressor2)Septic shock with need for vassopressor

ICU ADMISSION IF THREE MINOR OR ONE MAJOR CRITERIA ARE METICU ADMISSION IF THREE MINOR OR ONE MAJOR CRITERIA ARE MET

Pneumonia Severity Index (PSI)Pneumonia Severity Index (PSI)points

Demographic factors male Age in yrs

female Age in yrs - 10

Nursing home resident Age in yrs + 10

Comorbid illness Neoplastic disease +30

Liver disease +20

CHF +10

Cerebrovascular disease +10

Renal disease +10

PSI (cont….)PSI (cont….)Points

Physical examinaton finding

Altered mental status +20

Respiratory rate >30 +20

SBP < 90 mm of Hg +20

Temp < 35 ◦C or > 40◦C +15

Pulse Rate >= 125 +10

Laboratory finding pH < 7.35 +30

BUN > 10.7 +20

Na < 130 mEq +20

Glucose > 250 mg/dl +10

Hematocrit < 30 +10

pO2<60 or SpO2<90 +10

Pleural effusion +10

score class Mortality( 30 days) management

< 70 I or II <1% OPD

71-90 III 2.8% Clinical judgement

91-130 IV 8.2-9.3% hospitalization

>130 V 31.1% hospitalization

Recommended empirical therapy for Recommended empirical therapy for HCAPHCAP

Combination therapy with Combination therapy with antipseudomonal cephalosporin or a carbapenem orantipseudomonal cephalosporin or a carbapenem or a beta–lactam/beta-lactamase inhibitora beta–lactam/beta-lactamase inhibitor PLUSPLUS antipseudomonal floroquinolone or aminoglycosideantipseudomonal floroquinolone or aminoglycoside Linezolide/vancomycin should be added to this Linezolide/vancomycin should be added to this

combination if risk of MRSA is highcombination if risk of MRSA is high

Antibiotic Treatment of HCAPAntibiotic Treatment of HCAP

Four Major Principles Underlie the Management Four Major Principles Underlie the Management of HCAPof HCAP

Avoid untreated or inadequately treated HCAP, failure Avoid untreated or inadequately treated HCAP, failure to do so is a consistent factor associated with to do so is a consistent factor associated with increased mortality.increased mortality.

Recognize the variability of bacteriology from one Recognize the variability of bacteriology from one hospital to another, one department from another and hospital to another, one department from another and one time period to another.one time period to another.

Avoid the overuse of antibiotics by focusing on Avoid the overuse of antibiotics by focusing on accurate diagnosis, tailoring therapy and limit duration accurate diagnosis, tailoring therapy and limit duration of therapy to the minimal effective period.of therapy to the minimal effective period.

Apply prevention strategies aimed at modifiable risk Apply prevention strategies aimed at modifiable risk factors.factors.

SummarySummary HCAP is a separate entity than CAPHCAP is a separate entity than CAP Etiology of HCAP is more similar to that of HAP/VAPEtiology of HCAP is more similar to that of HAP/VAP Patients with are more likely to harbor MDR organisms than Patients with are more likely to harbor MDR organisms than

CAPCAP Patients with HCAP are more likely to get inappropriate Patients with HCAP are more likely to get inappropriate

antibiotic therapy antibiotic therapy The chance of developing resistance , length of hospital stay The chance of developing resistance , length of hospital stay

and mortality is higher in HCAPand mortality is higher in HCAP in case of suspicion of HCAP, it should be treated with broad in case of suspicion of HCAP, it should be treated with broad

spectrum antibiotic after sending a culture. Then from the spectrum antibiotic after sending a culture. Then from the third day onward effort should should be made to descalate third day onward effort should should be made to descalate the antibiotic therapy depending on the culture report i.e a the antibiotic therapy depending on the culture report i.e a narrow spectrum antibiotic against the culprit pathogen narrow spectrum antibiotic against the culprit pathogen should be used if culture positive or treatment concordant should be used if culture positive or treatment concordant with CAP can be used if culture negative with CAP can be used if culture negative

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