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Hcap & Hap. Pamela Charity, MD Cathryn 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. Pneumonia. Fever Leukocytosis Infiltrate on CXR.

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Hcap hap

Hcap & Hap

Pamela Charity, MD

Cathryn Caton, MD, MS


Objectives
Objectives

  • Define pneumonia

  • Define HAP and review the characteristics

  • Define HCAP

  • Diagnosing HCAP and HAP

  • Treatment of HCAP and HAP

  • Review treatment algorithm


Pneumonia
Pneumonia

  • Fever

  • Leukocytosis

  • Infiltrate on CXR


Hospital acquired pneumonia
Hospital Acquired Pneumonia

  • Category of pneumonia that occurs 48 hours or more after admission

  • Encompasses

    • healthcare associated pneumonia and

    • ventilator associated pneumonia


Hospital acquired pneumonia1
Hospital Acquired Pneumonia

  • Time of onset

    • Is an epidemiologic variable and

    • Risk factor for specific pathogens and

    • Affects outcomes


Hospital acquired pneumonia2
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 pneumonia3
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
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
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
Choosing Empiric Antibiotics

  • HCAP and HAP are treated similarly

  • Think about multi-drug resistant pathogens

    • Gram Neg

      • PseudomonaAeruginosa – some are only sensitive to polymyxin B

      • SerratiaMarcescens

      • Klebsiella

      • Enterobacter

      • Acinetobacter

    • Gram Positive

      • MRSA

      • VRE



De escalation of antibiotic therapy
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



References
References

ATS/IDSA Guidelines

Am J RespirCrit Care Med Vol 171. pp 388-416, 2005


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