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HCAP & HAPPamela Charity, MDCathryn Caton, MD, MS
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OBJECTIVES Define pneumonia
Define HAP and review the characteristics
Define HCAP
Diagnosing HCAP and HAP
Treatment of HCAP and HAP
Review treatment algorithm
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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
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PNEUMONIA Fever Leukocytosis Infiltrate on CXR
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HOSPITAL ACQUIRED PNEUMONIA Category of pneumonia that occurs 48 hours
or more after admission
Encompasses
healthcare associated pneumonia and
ventilator associated pneumonia
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HOSPITAL ACQUIRED PNEUMONIA Time of onset
Is an epidemiologic variable and
Risk factor for specific pathogens and
Affects outcomes
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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
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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
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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
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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.
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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
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CHOOSING EMPIRIC ANTIBIOTICS
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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
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TREATMENT ALGORITHM
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REFERENCES
ATS/IDSA GuidelinesAm J Respir Crit Care Med Vol 171. pp
388-416, 2005