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What is nosocomial pneumonia? What are the types of NAP?

-hospital acquired pneumonia (HAP)

-ventilator associated pneumonia (VAP)
-health care associated pneumonia (HCAP)


Hospital acquired pneumonia, Ventillator acquire pneumo, & Health care associated pneumonia definition?

-HAP: developes more than 48hrs after admission to hospital

-VAP: development of pneumonia in a mechanically ventilated patient 48 hrs after endotracheal intubation

-HCAP: development of pneumonia in an outpatient setting in an individual with extensive health care contact.


Risks of HCAP

-abx in last 3mo
-hospitalization in last 3mo of at least 2 day duration
-resident of a nursing home or extended care facility
-home infusion therapy within the last month
-long term dialysis
-home wound care
-family member with an infection involving a multiple drug resistant pathogen


Whats different in NAP than CAP?

NAP has:
-change in normal flora (develops different resistance patterns)
-different pathogens
-high frequency of drug resisitance
-pts have worse underlying health status


Pathophysiology of NAP

-colonization of the stomach and pharynx, these bugs get there because of placement of NG tubes.

*within 48hrs of admission 75% of seriously ill patients will have upper airway colonization with organisms from the hospital.


Most common NAP bugs

-staphlococcus aureus
-pseudomonas aeruginosa
-gram - rods
-klebsiella pneumoniae
-e. coli


Most common bugs causing VAP?

-P. aeruginosa
-Stenotrophomonas maltophilia


Signs and symptoms?

-same as community acquired pneumonia but more severe.


What are the diagnostic clues of each bug causing pneumonia?
-strep pneumo

-pseudomonas, haemophilus, pneumococcal



strep: rust colored sputum

pseudo: green sputum

Klebsiella: red currant jelly sputum

Anaerobic: foul smelling or bad tasting sputum


Risk factors and features of Klebsiella pneumonia?

-RF: elderly, alcoholic, debilitated hospital pts

-Features: gram - member
-can cause extensive pulmonary necrosis
-cavitations seen on xray
-abscess formation
-pleural adhesions(scar)


Sx of Klebsielle pneumonia?

-rapid onset of sever symptoms

-high fever and chills
-flulike sx
-cough productive of currant jelly like sputum


Klebsiella radiographic clues

-extensive lobar consolidation
-air bronchograms
-bulging fissure sign
-cavitary lesions (gas filled space in an area of consolidation)


Tx of Klebsiella pneumonia

*resistant to all of the big gun abx

-use impenem-cilastatin or meropenem


Legionella PNA sx
-gram stain?
-clinical findings

-GI sx (esp. diarrhea)**(ONLY pna to have diarrhea sx)

-neurologic findings (esp. confusion)

-fever >39C

Gram stain of respiratory secretions shows many neutrophils, but few, if any microorganisms.

-hepatic dysfunction
-failure to respond to beta-lactam and/or aminoglycoside abx


Is legionella transmitted from person to person??

Treatment of legionella?

-nope, from contaminated water supply

-tx is macrolides of respiratory FQ


Staphylococcus aureaus pna
-commonly shows up when?
-what bacteria is this?
-MRSA associated with?

-often seen post influenza

-group A streptococcus (GAS; S, pyogenes)

-MRSA associated with high mortality and necrotizing pneumonia


Pseudomonas aeruginosa pneumonia

-gram +/-
-how does their breath smell?

-gram negative
-cough productive of purulent sputum, dyspnea, fever, chills, confusion, and sever systemic toxicity

-sweet, grape-life odor of breath


Risk factors of Pseudomonas aeruginosa pna?

-bronchiectasis (cystic fibrosis)
-repeated abx use
-prolonged oral glucocorticoid use in pts w/ structural lung disease (COPD)
-prevously hospitalizations


General treatment for NAP?

-Start with imipenem** or meropenem
--suspect legionelle add on levofloxacin or moxifloxacin
--if suspect MRAS add on Vancomycin

-if suspect pseudomonas : imipenem* or cefepime or zosyn + cipro* or tobramycin


Prevention of NAP?

-avoid acid-blocking meds
-decontamination of the oropharynx
-patient positioning
-subglottic drainage
-preventing aspiration
-hand washing
-clean equipment