HCAP & HAPPamela Charity, MDCathryn Caton, MD, MS

OBJECTIVES Define pneumonia

Define HAP and review the characteristics

Define HCAP

Diagnosing HCAP and HAP

Treatment of HCAP and HAP

Review treatment algorithm

KEY MESSAGES Be familiar with the following:

Definition of both terms Start antibiotics within 4 hours of making the

diagnosis Know which antibiotics to start empirically Know where to access the antibiogram Know how and when to de-escalate antibiotic

therapy

PNEUMONIA Fever Leukocytosis Infiltrate on CXR

HOSPITAL ACQUIRED PNEUMONIA Category of pneumonia that occurs 48 hours

or more after admission

Encompasses

healthcare associated pneumonia and

ventilator associated pneumonia

HOSPITAL ACQUIRED PNEUMONIA Time of onset

Is an epidemiologic variable and

Risk factor for specific pathogens and

Affects outcomes

HOSPITAL ACQUIRED PNEUMONIA Early onset

Within first 4 days Better prognosis More likely to be caused by antibiotic-sensitive

bacteria

Above is true unless patient Received prior antibiotics Have had prior hospitalization within 90 days

Greater risk for colonization and infection with MDR pathogens

HOSPITAL ACQUIRED PNEUMONIA Late onset

5 days or more

More likely to be caused by MDR pathogens risk factors for MDR

Antimicrobial therapy in preceding 90 days Presence of risk factors for HCAP Immunosuppresive disease/therapy

Increased morbidity and mortality

HEALTHCARE ASSOCIATED PNEUMONIA

Category of pneumonia in patients with recent close contact with the health care system

Hospitalized for 2 or more days within last 90 days

Resides in nursing home or long-term care facility

Received recent IV antibiotic therapy, chemotherapy, or wound care within past 30 days

Hemodialysis

MAKING THE DIAGNOSIS History – this will determine the classification

of pneumonia

Physical exam findings

Laboratory data

Radiographic findings

Antibiotics should be initiated within 4 hours of making the diagnosis.

CHOOSING EMPIRIC ANTIBIOTICS HCAP and HAP are treated similarly Think about multi-drug resistant pathogens

Gram Neg Pseudomona Aeruginosa – some are only sensitive to

polymyxin B Serratia Marcescens Klebsiella Enterobacter Acinetobacter

Gram Positive MRSA VRE

CHOOSING EMPIRIC ANTIBIOTICS

DE-ESCALATION OF ANTIBIOTIC THERAPY

This may be appropriate if Clinical improvement at 48-72 hours Cultures are positive Treat for 7-8 days and reassess patient Single agent such as moxifloxacin may be

appropriate

May stop antibiotics if clinical improvement at 48-72 hours and cultures are negative

TREATMENT ALGORITHM

REFERENCES

ATS/IDSA GuidelinesAm J Respir Crit Care Med Vol 171. pp

388-416, 2005