Pneumonia, nosocomial

Notes
  • Nosocomial pneumonia or Hospital-acquired pneumonia (HAP) is pneumonia contracted by a patient in a hospital at least 2 days or more after admission.
  • HAP is the most common cause of death among nosocomial infections and it is the 2nd most prevalent nosocomial infection after UTIs.
  • Most of them are caused by gram-negative bacilli
  • About 19% of cases of HAP are caused by Staphylococcus aureus, majority of which are of the MRSA type.
  • A small proportion of HAPs are caused by viruses that such as influenza virus, respiratory syncytial virus, and cytomegalovirus (especially in immunocompromised host).

##The common sources / types of nosocomial infections are:

  • IV devices that are exposed to contamination with staphylococci and other Gram-positive bacteria
  • Wounds from indwelling urinary catheters that are likely to be infected with Gram-negative bacteria
  • Wounds from tracheostomy and ventilators that are likely to be infected with the mixed bacterial flora
  • Post-surgical wounds that are also likely to be infected with various bacteria.
Symptoms
  • Shortness of breath
  • Cough with sputum that may be rust-coloured.
  • Cough without sputum
  • Fever (≥ 38 deg C)
  • Chest pain (mainly pleuritic)
  • Reduced chest movement
  • Crackles
  • Wheezing
  • Tachypnoea (respiratory rate or the breathing per minutes cut-offs for various ages are as follows: 0-2 months old ≤ 60, 2-12 months old ≤ 50, 12-60 months old ≤  40 and adults and children above 5yrs  ≤  30
  • Indrawing of chest (in severe cases)
  • Cyanosis (in severe cases)
  • Crepitations
  • Confusion and/or disorientation
  • Newly developed infiltrate on the chest X-Ray
Diagnosis
  • Clinical examination
  • Complete Blood Count
  • Chest X-ray to check for severe pneumonia, complications of pneumonia, TB and cardiac disease.
  • Blood culture
  • Lumber puncture & culture
  • It is advisable to test for HIV in order to modify and maximize the management
Differential
  • Severe pneumonia
  • Severe anemia
  • Asthma
  • Cardiac disease
  • TB
  • Atelectasis
  • Pulmonary embolism
Prevention
  • Decrease aspiration by the patient
  • Preventing cross-contamination from hands of personnel
  • Appropriate disinfection or sterilization or respiratory therapy devices
  • Vaccines to protect against particular infections
  • Education of hospital staff and patients.
Management

##Use combination of  antibiotics with activities against Gram +ve and Gram -ve bacteria:

  • IV/IM Cloxacillin PLUS IV/IM gentamicin
  • IM/IV Ceftazidime PLUS EITHER IM/IV gentamicin OR IV Ciprofloxacin

##In case methicillin-resistant Staphylococcus aureus (MRSA)

  • Add IV Vancomycin to the above regime
  • IV Imipenem + Cilastatin (reserve drug)
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