In this episode of Hospital Medicine Unplugged, we tackle hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP)—spot early, culture smart, treat right, and prevent relentlessly.
We open with the definitions: HAP = ≥48 h after admission in non-ventilated patients; VAP = ≥48 h after intubation. Both drive ICU stays, mortality, and costs, with Gram-negatives + MRSA leading the charge and MDROs reshaping therapy.
Risk factors: prior antibiotics, prolonged hospitalization, intubation, comorbidities (lung disease, diabetes, CKD, immunosuppression), and high local MDRO burden. Pathogenesis is microaspiration + impaired defenses + hospital flora colonization, amplified by invasive devices.
Diagnosis: need new/progressive infiltrate + fever/leukocytosis/purulent secretions or worsening oxygenation. Always get respiratory samples before antibiotics—sputum/ETA/BAL depending on setting. Molecular panels can speed ID and resistance calls, but stewardship is key. Biomarkers (CRP, procalcitonin) support, but don’t replace cultures.
Treatment: • Start empiric antibiotics promptly after cultures, not before. • Low MDRO risk → standard-spectrum (e.g., ceftriaxone, ampicillin-sulbactam). • High MDRO risk → cover Pseudomonas + MRSA, with dual antipseudomonal therapy only in severe illness or recent IV antibiotics. • De-escalate at 48–72 h based on cultures and clinical response. • Duration: 7 days (shorter courses safe if improving; extend if Pseudomonas, slow response, or complications). • Adjuncts: optimize PK/PD dosing in critically ill; consider inhaled antibiotics in refractory MDRO cases.
Supportive care: oxygen and ventilation as needed, fluids, hemodynamic support, physiotherapy, nutrition, and aspiration precautions. ICU transfer if hypoxemia, shock, or organ failure.
Prevention bundles: • Non-ventilated patients: daily oral care (mechanical brushing > chlorhexidine rinses), aspiration precautions (HOB 30–45°, dysphagia screening), early mobilization, sedation minimization, hand hygiene. • Ventilated patients: subglottic secretion drainage, closed suction, avoid routine circuit changes, minimize sedation, and elevate HOB. Selective digestive decontamination can reduce VAP/mortality but use cautiously (resistance risk). • System-wide: minimize unnecessary antibiotics/acid suppression, maintain vaccines, embed multimodal prevention.
Complications: ARDS, empyema, lung abscess, sepsis, septic shock, renal failure, cardiac events, thromboembolism, longer LOS, readmissions. Risk of complications climbs with age, comorbidities, aspiration, and inappropriate empiric therapy.
Prognosis: • NV-HAP mortality 11–22%; VAP and ventilated HAP 21–29%. • ICU HAP → +82% 30-day mortality; VAP → +38%. • 1-year mortality ~35–41% even in survivors. • MDRO infections, multilobar infiltrates, vasopressor use, or failed early response = poor outcomes.
Bottom line: spot early, culture before antibiotics, hit hard if risk factors, de-escalate fast, shorten duration, and prevent with bundles. That’s how you save lungs, save lives, and save antibiotics.
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