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Noscocomial Pneumonia
Andrew Shorr, MD, MPH
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Overview
Definition
Pathogenesis
Risk factors
Microiolog!
Diagnosis "reatment
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Definition
#nfection of $ulmonar! $araench!ma
Occurs %&'() hrs after admission
*+cludes $rocesses incuating $rior to
admission
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*$idemiolog!
Occurs in '-. cases $er -,... admissions
#ncidence /'). fold higher in M0 $atients
Second most common nosocomial infection
Mortalit! rate a$$roaches (.1
Attriutale mortalit!2 33'.1
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Pathogenesis
Host defenses im$aired
#noculum sufficient to cause infection enterslower res$irator! tract
0irulent organism
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Pathogenesis
Routes of entr!
4Microas$iration
4#nhalation
4Hematogenous s$read
4Direct e+tension
40ia *" tue
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Pathogenesis
Microas$iration
4Most common route of entr!
4OP flora in hos$itali5ed $atients is distinct
4Ma! as$irate 6# contents
4Occurs in %1 of health! su7ects during slee$
431 of moderatel! ill and (1 of #89 $atientsoro$har!n+ coloni5ed ! *6N:
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Pathogenesis
6ross as$iration2 rare
Aerosol2 ;egionella, M":
*" tue
4:!$ass host defenses aove cords
4#m$airs mucocilliar! clearance
4Secretions leak around *" tue
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Risk factors Patient'related
4Age
48NS status
49nderl!ing disease
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Microiolog! S$ectrum different from 8AP
Organisms de$end on2
4"ime of onset
4Severit!4Patient's$ecific factors g> immune status=
6enerall! concerned aout2
4*6N:
4S> aureus
4Pol!microial in .1 $atients on M0
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8lassif!ing $atients
*arl! onset2 ? da!s after admission
;ate onset2 @ da!s after admission
Determine risk factors
Determine severit!
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8lassif!ing $atients
O n s e t A n ! t i m e
N o
O n s e t A n ! t i m e
e s
R i s k B a c t o r s
M i l d t o M o d e r a t e
* a r l ! O n s e t ; a t e O n s e t
N o
O n s e t A n ! t i m e
e s
R i s k B a c t o r s
S e v e r e
S e v e r i t ! o f # l l n e s s
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Risk factors
Pathogen Risk factors
Anaroes Adominal surger!,
as$iration
S> aureus 8oma, AODM, renal
failure
;egionella 8orticosteroids
Psuedomonas ;ong #89 sta!,corticosteroids,
underl!ing lung d5,
$rior a+ use
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Definition of severe HAP
Admission to #89
Res$irator! failure
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Microiolog!
Mild to moderate HAP or earl! severe HAP
4*nteroacter
4* coli
4Proteus
4Serratia
4MSSA
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Microiolog!
Severe HAP
4Psuedomonas
4Acinetoacter
4MRSA
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Microiolog!
Risk factor for S> aureus
48oma on admission
468S ? for at least )%hrs after admission
4Asence of corticosteroid t+
4Recent trauma
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Microiolog! Risk factors for ;egionella
4Malignanc!
4Neutro$enia
49se of corticosteroids
4Renal failure
48!toto+ic chemothera$!
No relationshi$ with
4MS
4Prior a+ use
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Diagnosis
8linical $icture often confusing
Differential diagnosis road
Role for invasive $rocedure controversial
No diagnostic a$$roach without $rolems
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8CR
New infiltrate often reEuired for d+ of HAP
Bever ma! $recede infiltrate
AP films difficult to inter$ret in #894)/1 of infiltrates ! 8" scan missed ! 8CR
4#f underl!ing 8CR anormal g> ARDS=,
locating new $rocess difficult Man! $neumonia mimics
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8CR
As$iration Alveolar hemorrhage
Atelectasis Pulmonar! edema
ARDS Pleural effusion
Pulmonar!
infarct
:OOP
Radiogra$hic Mimics of Pneumonia
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8CR
Atelectasis
48ommon
4Resolves within %& hrs
6astric as$iration
4.1 of alert $ts on M0 ma! as$irate
4((1 as!m$tomatic des$ite large volume
as$iration
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8CR
No feature allows differentiation of
$neumonia from non$neumonic $rocess
8orrelation etween 8CR diagnosis and
auto$s! $oor
Providing radiologist with clinical data ma!
worsen accurac! of 8CR
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S$utum culture
Onl! 331 of $atients coloni5ed develo$
HAP
Recover! of $athogen from tracheal
secretion not diagnostic for $neumonia
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S$utum culture
6ram stain4#f no acteria, ?1 $roailit! HAP
4#f @-.Foil immersion field on .1 HAP
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8linical im$ression
New infiltrate, $urulent secretion GF'
feverFleukoc!tosis2 3.1 incidence HAP
Overall MD accurac!2 ((1
4*+clude d+ HAP '' &1
4D+ HAP '' /)1
*ven if clinical d+ HAP correct, incorrect
a+ in %%1 cases
Bagon et al> 8hest> -32 %('3>
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:ronchosco$!
"wo techniEues4PS:
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:ronchosco$!
Positive culture2 -.3or -.%8B9
Pneumonia usuall! not clinicall! $resent unless -.%
8B9 or greater
"hreshold not asolute 8ulture results elow threshold ma! re$resent earl!
disease
43.1 of $atients with @-.)ut ? -.38B9 eventuall!
develo$ed HAP
S$ecificit!2 .1 for :A; and PS:
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:ronchosco$!
0
10
20
30
40
50
60
70
80
Culture Threshold
FalsePositive(%)
ETA
A!
P"
S$ecificit! and Balse Positives
-.3 -.% -. -./
"orres et al> ARRD> -32 )'(>
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Diagnosis
Sensitivit!2 '(1
Balse negative rate raises concern aout
withholding a+
4No e+cess mortalit! in $atients with neg> BO:
even if clinical $icture cFw HAP
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"reatment
Never use aminogl!coside alone
4Poor lung $enetration
uinolones and aminogl!cosides have$rolonged $ostantiiotic effect
Anti$seudomonal thera$! reEuires multi$le
agents Iith a$$ro$riate thera$!2 (.'&.1 survival
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"reatment
*6N:
4 *nteroacter
4 *> coli
4 Jlesiella
4 Proteus4 Serratia
MSSA
8e$halos$orin
4 )nd generation or
non$suedomonal 3rd
generation
:eta lactamFlactamase
inhiitor
BluroEuinolone
Core or#a$is%s Core a$ti&ioti's
Mild to moderate HAP, no unusual risk factors,onset an! time or severe HAP with earl! onset
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"reatment
Anaroes S> aureus
;egionella
Pseudomonas
8lindam!cin or eta
lactamF lactamase
inhiitor
GF' 0ancom!cin
Macrolide BluroEuinolone
Core or#a$is%sPlus Core a$ti&ioti'sPlus
Mild to moderate HAP with risk factors, onset an!time
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"reatment
Pseudomonas
Acinetoacter
8onsider MRSA
Aminogl!coside BluroEuinolone
A5treonam
Anti$suedomonal
P8N or 8e$halos$orin
#mi$enim
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"reatment Design2 D:R8", Multicenter
Patients
48linical d+ of nosocomial $neumonia
4Stratified ! severit! illness
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"reatment
0
10
20
30
40
5060
70
80
+0
Trova,lo-a'i$
Ci)ro,lo-a'i$
*fficac! All 8ause
Mortalit!
8ure Rate for
Psuedomonas
1 of
Patients
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"reatment
Design2 D:R8", multicenter
Patients
4Mechanicall! ventilated
48linical d+ GF' :A;
Sam$le si5e2 nK)(
#ntervention
48efe$ime G amikacin vs cefta5idime G amikacin
:eaucaire 6, et al> Ann Anesth Reanim -L-&2 -&/'-
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"reatment
0
10
20
30
40
50
60
.e'over*
rate
All Patie$ts /o'u%e$ted
P$eu%o$ia
Ce,taidi%e
Ce,e)i%e
$ K .>.
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Drug resistance
6rowing $rolem
8ara$enems no longer acce$tale
monothera$! for 0AP Historical use of a+ likel! cul$rit
Resistance now an issue for
4Pseudomonas4S> aureus
4Acinetoacter
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Acinetoacter resistance
Acinetoacter 0AP associated with high
mortalit!
Recent #89 outreaks of MDR A>aumanni re$orted
Ma7or risk factor for infection with A
umanni48efta5idime use .=
Husni RN, et al> 8H*S" -L --2-3(&'-3&)
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Prevention
#nfection control
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Prevention
8hoice of ulcer $ro$h!la+is
4Sucralfate vs ranitidine 8ro$ rotation of antiiotics
Selective gut decontamination
9se of c!tokines46'8SB
4#BN
Co$troversial a$d e-)eri%e$tal o)tio$s
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8onclusions
HAP is freEuent
HAP associated with e+cess mortalit!
Pathogens distinct
Diagnosis is difficult
A$$roach to thera$! em$iric
Prevent o$tions availale