hospital-acquired pneumonia

INTRODUCTION

Hospital-acquired pneumonia (HAP) is defined as the clinical development of pneumonia occurring at least 48 hours after admission to hospital and not incubating at the time of admission. The lungs are the third most common site of nosocomial infections (after the urinary tract and the bloodstream). HAP accounts for 31% of all nosocomial infections and affects 0.5% to 2.0% of all hospital inpatients. HAP is a major cause of morbidity and mortality among hospital patients. All-cause mortality among patients with HAP has been reported at up to 70%. However, most patients who are critically ill with HAP and subsequently die have an underlying severe illness that is ultimately the cause of death. Therefore, a more accurate estimate of the mortality directly attributable to HAP ranges from 33% to 50%. Development of HAP prolongs the hospital stay by an estimated 7 to 9 days. Because of its frequency and considerable morbidity and mortality, HAP is a major health problem.

Organisms colonizing the oropharynx of hospital patients represent the most common cause of HAP. Such organisms may include Enterobacter spp., Escherichia coli, Klebsiella spp., Proteus spp., Serratia marcescens, Hemophilus influenzae, Pseudomonas aeruginosa, Acinetobacter spp., methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant Staphylococcus aureus (MRSA), and Streptococcus pneumoniae. The spectrum of potential pathogens in a particular case may be predicted by evaluating factors such as severity of the pneumonia, presence of comorbid conditions, previous use of antibiotics, and length of hospital stay.
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At the authors’ institution, an 1100-bed university- affiliated tertiary care hospital in Toronto, Ontario, with approximately 16 800 admissions each year and an average length of stay of 8.5 days, the currently recommended empiric therapy for HAP in a ward patient is ceftriaxone. According to long-term antimicrobial resisĀ­tance data collected by the Department of Microbiology, Sunnybrook and Women’s College Health Sciences Centre, resistance to ceftriaxone in Klebsiella pneumoniae at this institution climbed from 4% in 1998 to 15% in 2003. A similar trend was seen for both Enterobacter spp., with a rise in resistance from 10% in 1998 to 55% in 2002, and Serratia marcescens, with a rise in resistance from 0% in 2001 to 55% in 2002. The changing resistance patterns of these organisms may necessitate a change in the empiric management of HAP. As a result of evidence indicating a higher risk of death among patients with HAP for whom appropriate empiric antibiotic therapy is delayed, the initial use of broad-spectrum antibiotics followed by de-escalation therapy when culture and sensitivity results become available has been recom- mended. The appropriate choice of empiric antimicrobial therapy requires an awareness of potential causative pathogens, antibiotic susceptibility data, and host factors that may contribute to infections or development of resistance in a given institution.

The objectives of this study were to determine the current approach to management of patients with HAP at the authors’ hospital and to determine if there was a need to change the institution’s guidelines for the empiric management of HAP.
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