Nosocomial Pneumonia

Aka: Nosocomial Pneumonia, Hospital Acquired Pneumonia

1. See Also
   1. Pneumonia
2. Epidemiology
   1. Complicates up to 1% of hospitalizations
   2. Mortality: 30-50%
3. Etiologies
   1. Aspiration following Cerebrovascular Accident (CVA)
      1. Streptococcus Pneumoniae
      2. Anaerobic Bacteria
   2. Mechanical Ventilation
      1. Coliform bacteria (Gram Negative Bacteria)
      2. Pseudomonas aeruginosa (most common)
      3. Staphylococcus aureus (consider MRSA)
   3. Organ Failure
      1. Coliform bacteria (Gram Negative Bacteria)
   4. Air Conditioner Contamination
      1. Legionella pneumonia
   5. Airway Obstruction
      1. Anaerobic Bacteria
   6. Corticosteroid use
      1. Yeast
      2. Pneumocystis carinii Pneumonia
   7. Neutropenia (<500 Neutrophils/mm3)
      1. Aspergillus
      2. Candidiasis
4. Symptoms
   1. Fever
   2. Purulent Sputum
5. Labs
   1. Complete Blood Count
      1. Leukocytosis
   2. Arterial Blood Gas
      1. Increased A-a Gradient
6. Radiology: Chest XRay
   1. New or progressive lung infiltrate
7. Management: Antibiotics
   1. Imipenem 0.5 g IV q6 hours
   2. Meropenem 1.0 g IV q8 hours
   3. Aminoglycoside Combinations (2-3 antibiotics)
      1. Antibiotic 1: Aminoglycoside Options
         1. Gentamicin
         2. Tobramycin 5 mg/kg IV q24 hours
      2. Antibiotic 2 Options
         1. Ceftazidime 2 g IV q8 hours
         2. Piperacillin 4 g IV q6 hours
         3. Ticarcillin 4 g IV q6 hours
      3. Antibiotic 3 (consider)
         1. Clindamycin 450-900 mg IV q8 hours
   4. Ciprofloxacin Combinations (2 antibiotics)
      1. Antibiotic 1
         1. Ciprofloxacin 400 mg IV q12 hours
      2. Antibiotic 2
         1. Ticarcillin-Clavulanate (Timentin) 3.1 grams IV q6h
         2. Piperacillin-Tazobactam (Zosyn) 3.375 g IV q6 hours
   5. Organisms requiring additional antibiotic coverage
      1. Methicillin Resistant Staphylococcus Aureus (MRSA)
         1. Vancomycin 1 gram IV q12 hours given over 1 hour
      2. Legionella pneumonia
         1. Azithromycin 500 mg IV q24 hours or
         2. Broad spectrum Fluoroquinolone
            1. Trovafloxacin 300 mg IV q24 hours
            2. Levofloxacin 500 mg IV q24 hours
      3. Fungal Organisms (e.g. Aspergillus)
         1. Amphotericin B
8. References
   1. Gilbert (2001) Sanford Antimicrobial, p. 28
   2. Bowton (1999) Chest 115:28S-33S
   3. Cunha (2001) Med Clin North Am 85(1):79-114
   4. Kollef (1999) Clin Chest Med 20(3):653-70
   5. Weber (1999) Chest 115:34S-41S