Prevention Of Hospital-acquired Pneumonia Research Articles

2246 Mind the HAP – an initiative to improve the diagnosis, management and prevention of hospital acquired pneumonia on elderly care

Abstract Introduction The commonest nosocomial infection in the UK is Hospital Acquired Pneumonia (HAP), associated with prolonged length of stay and mortality. The HAP incidence on Elderly care wards was >5% of admissions, exceeding the national average. An initiative ‘Mind the HAP’ was launched which included doctors, nurses, pharmacists, SLTs, physiotherapists and coders to improve HAP diagnosis, management and prevention. Methods To monitor the effectiveness of the interventions 3 audit cycles were performed between 2019 and 2023. Several interventions were implemented between 2019–2023.A multidisciplinary steering committee was formed with 3 work streams (diagnosis, management and prevention). To improve the accuracy of diagnosis and management of HAP, focused educational sessions were conducted for junior doctors with monthly meetings with coders. Nurses championed implementing the HAP prevention strategies i.e. hand hygiene, mouth care and positioning at 30–45 degrees. Regular comprehensive training sessions were held. HAP awareness and education campaign was launched. Daily nursing huddles helped to identify high risk patients. Physiotherapists provide chest physiotherapy to yield sputum sample collection among pneumonia patients. An electronic dashboard of incidence of HAP against the preventative measures and sputum culture reports has been launched with help from informatics. Information leaflets on HAP were created for patient awareness. An electronic HAP power plan to facilitate diagnosis and management of HAP will be launched from February 2024. Results HAP incidence has dropped to <2%, diagnostic accuracy improved from 35% to 81%, and sputum collection has increased from 9% to 24%. The HAP Quality Improvement Project received first prize for the most impactful Quality Improvement initiative at the Trust-wide conference in 2023. The results have been shared with the regional Microbiologists. Conclusion The collaborative efforts coupled with effective leadership and guidance, have been pivotal to the success of ‘Mind the HAP’ project.

Impact of hospital-acquired pneumonia on the Medicare program.

Patient safety organizations and researchers describe hospital-acquired pneumonia (HAP) as a largely preventable hospital-acquired infection that affects patient safety and quality of care. We provide evidence regarding the consequences of HAP among 2019 Medicare beneficiaries. Retrospective case-control study. Calendar year 2019 Medicare beneficiaries with HAP during an initial hospitalization, defined by International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding on inpatient claims (n = 2,457). Beneficiaries with HAP were matched using diagnosis-related group (DRG) codes with beneficiaries who did not experience HAP (n = 2,457). The 2019 calendar year Medicare 5% Standard Analytic Files (SAF), for inpatient, outpatient, physician, and all postacute hospital settings. The case group (HAP) and control group (non-HAP) were matched on disease severity, age, sex, and race and were compared for hospital length of stay, costs, and mortality during the initial hospitalization and across settings for 30, 60, and 90 days after discharge. The 2019 fiscal year MedPAR Claims data were used to determine Medicare costs. Medicare beneficiaries with HAP were 2.8 times more likely to die within 90 days compared with matched beneficiaries who did not develop HAP. Among those who survived, beneficiaries with HAP spent 6.6 more days in the hospital (69%) and cost the Medicare program an average of $14,487 (24%) more per episode of care across initial inpatient and postdischarge services. The findings of higher mortality and cost among Medicare beneficiaries who develop HAP suggest that HAP prevention should be prioritized as a patient safety and quality initiative for the Medicare program.

Impact of Oral Care for Intensive Care Unit Patient on Pneumonia Infection Prevention: Literature Review Study

Background: Oral cavity bacteria can be mostly harmful if inhaled into the lungs. Hospital acquired pneumonia (HAP), a critical condition that presents clinically two or more days after hospitalization, which may increase the risk of mortality. Lacking oral care can lead to Hospital acquired pneumonia. Objective: to explore effective oral care consequence on hospital acquired pneumonia prevention. Methods: This review article is performed according to the PRISMA guidelines. The literature exploration was done in Google Scholar and PubMed databases for articles published between 2017 and 2020. The search words were “oral care, oral hygiene, intensive care, critical care, ICU, respiratory infection, lung infection, pneumonia, and adult". Results: A total of 6 studies were included, the studies were randomized controlled trials (RCTs) and observational studies. Oral care with tooth brushing and purified water twice daily can significantly reduce the incidence of HAP. Brushing patient mouth with chlorhexidine is also effective in decreasing the HAP incidence. Implementing oral care protocols in ICU with chlorhexidine solution and nurse education can significantly lower the incidence of HAP. Conclusions: Good oral and dental care, particularly with tooth brushing and purified water twice daily, can significantly reduce the incidence of HAP in intensive care unit patients.

Expository Methods of Bundles HAP Affected the Implementation of HAP Prevention of Adult Inpatient Unit

Hospital-acquired pneumonia (HAP) incidents in private hospitals in Bandung reached 0.11 % -1.03 %. HAP affects the quality of hospital services related to patient safety. One of the methods used for socializing implementation of HAP prevention was the expository method means learning method that is directly implemented to maintain contact between the speaker and audience. The purpose of this study was to determine the effect of the expository method of education on HAP bundles on the implementation of HAP prevention in the adult inpatient units. The study was designed by pre-experimental design one group pretest-posttest. A total of 16 associate nurses were part of the research using the purposive sampling technique in the adult inpatient units. The variable in the study was the implementation of HAP prevention which was measured by using an observation sheet. Wilcoxon tests were used to compare the scores between pretest-posttest. The researched result was P-value 0.000 (P-value < α 0.05), meaning the expository method of education on HAP bundle affected the implementation of HAP prevention in the adult inpatient unit. Suggestions derived from this study are to advise the infection prevention and control committee to implement the expository method in socializing bundles to prevent infections categorized as HAIs to health workers and to perform a regular evaluation.

Registered nurses\u2019 experiences of providing respiratory care in relation to hospital- acquired pneumonia at in-patient stroke units: a qualitative descriptive study

ObjectiveThis study aimed to describe registered nurses’ (RNs) experiences of providing respiratory care in relation to hospital acquired pneumonia (HAP), specifically among patients with acute stroke being cared for at in-patient stroke units.BackgroundOne of the most common and serious respiratory complications associated with acute stroke is HAP. Respiratory care is among the fundamentals of patient care, and thus competency in this field is expected as part of nursing training. However, there is a paucity of literature detailing RNs’ experiences with respiratory care in relation to HAP, specifically among patients with acute stroke, in the context of stroke units. As such, there is a need to expand the knowledge base relating to respiratory care focusing on HAP, to assist with evidence-based nursing.DesignA qualitative descriptive study.MethodEleven RNs working in four different acute stroke units in Southern Sweden participated in the current study. The data were collected through semi-structured interviews, and the transcribed interviews were analysed using inductive content analysis.ResultsThree overarching categories were identified: (1), awareness of risk assessments and risk factors for HAP (2) targeting HAP through multiple nursing care actions, and (3) challenges in providing respiratory care to patients in risk of HAP. These reflected the similarities and differences in the experiences that RNs had with providing respiratory care in relation to HAP among in-patients with acute stroke.ConclusionsThe findings from this study suggest that the RNs experience organisational challenges in providing respiratory care for HAP among patients with acute stroke. Respiratory care plays a vital role in the identification and prevention of HAP, but our findings imply that RNs’ knowledge needs to be improved, the fundamentals of nursing care need to be prioritised, and evidence-based guidelines must be implemented. RNs would also benefit from further education and support, in order to lead point-of-care nursing in multidisciplinary stroke teams.

Cortisol total/CRP ratio for the prediction of hospital-acquired pneumonia and initiation of corticosteroid therapy in traumatic brain-injured patients

BackgroundTo propose a combination of blood biomarkers for the prediction of hospital-acquired pneumonia (HAP) and for the selection of traumatic brain-injured (TBI) patients eligible for corticosteroid therapy for the prevention of HAP.MethodsThis was a sub-study of the CORTI-TC trial, a multicenter, randomized, double-blind, controlled trial evaluating the risk of HAP at day 28 in 336 TBI patients treated or not with corticosteroid therapy. Patients were between 15 and 65 years with severe traumatic brain injury (Glasgow coma scale score ≤ 8 and trauma-associated lesion on brain CT scan) and were enrolled within 24 h of trauma. The blood levels of CRP and cortisoltotal&free, as a surrogate marker of the pro/anti-inflammatory response balance, were measured in samples collected before the treatment initiation. Endpoint was HAP on day 28.ResultsOf the 179 patients with available samples, 89 (49.7%) developed an HAP. Cortisoltotal&free and CRP blood levels upon ICU admission were not significantly different between patients with or without HAP. The cortisoltotal/CRP ratio upon admission was 2.30 [1.25–3.91] in patients without HAP and 3.36 [1.74–5.09] in patients with HAP (p = 0.021). In multivariate analysis, a cortisoltotal/CRP ratio > 3, selected upon the best Youden index on the ROC curve, was independently associated with HAP (OR 2.50, CI95% [1.34–4.64] p = 0.004). The HR for HAP with corticosteroid treatment was 0.59 (CI95% [0.34–1.00], p = 0.005) in patients with a cortisoltotal/CRP ratio > 3, and 0.89 (CI95% [0.49–1.64], p = 0.85) in patients with a ratio < 3.ConclusionA cortisoltotal/CRP ratio > 3 upon admission may predict the development of HAP in severe TBI. Among these patients, corticosteroids reduce the occurrence HAP. We suggest that this ratio may select the patients who may benefit from corticosteroid therapy for the prevention of HAP.

Is intensive and comprehensive dysphagia rehabilitation effective in preventing hospital-acquired pneumonia in a convalescent rehabilitation ward?

To evaluate the effect of intensive and comprehensive dysphagia rehabilitation on the prevention of hospital-acquired pneumonia. In this non-randomized retrospective observational study, we compared two patient groups in a convalescent rehabilitation ward. One included patients after the introduction of an intensive and comprehensive rehabilitative program including various measures, such as nutritional support and respiratory physical therapy (intensive program group); the other included patients who had been admitted before the introduction of the above measures (control group). The primary endpoint was the onset of pneumonia during the hospital stay. A multivariate logistic regression analysis was used to determine the adjusted odds ratio for the relationship between dysphagia rehabilitation and pneumonia onset. In the intensive program group, 5 of 291 patients were diagnosed with pneumonia, while in the control group, 13 of 460 were diagnosed with pneumonia. The adjusted odds ratio for intensive and comprehensive dysphagia rehabilitation with respect to hospital-acquired pneumonia was 0.326 (95% confidence interval: 0.112-0.949, p=0.040). This intensive and comprehensive dysphagia rehabilitation program was thought to be effective in preventing hospital-acquired pneumonia in a convalescent rehabilitation ward.

1181. Significant Reduction of Non-Ventilator Hospital-Acquired Pneumonia (HAP) with a Prevention Bundle and Clinical and Leadership Feedback in a Large Integrated Healthcare System

BackgroundNon-Ventilator Hospital-acquired Pneumonia (HAP) is a prevalent healthcare-associated infection with mortality of 21%. HAP prevention literature is scant. We developed a definition enabling accurate surveillance to support this effort and implemented a prevention bundle based on available literature and characteristics of our high-performing centers.MethodsKaiser Permanente Northern California is an integrated healthcare system providing care for 4.4 million patients at 21 medical centers. Discharge diagnoses of HAP cases were reviewed for accuracy and factors permitting programmatic confirmation. A natural language extraction program identified new and persisting imaging findings, providing specificity. No other surveillance factors added specificity. Surgery, altered mental status, sedation, albumin <3 g/dl and tube feedings were identified as predictive risks. Seven interventions became part of a new pneumonia prevention order set for automatically identified high-risk patients: aggressive mobilization, upright posture for meals, swallowing evaluation before feeding, sedation restriction, elevated head of bed, oral care and feeding tube care. The project was fully implemented in 2015.ResultsResults were reported by 1,000 admissions and by 100,000 members served, to address a rapidly growing population. HAP decreased from 5.92 to 1.79/1000 admissions and 24.57 to 6.49/100,000 members and HAP case mortality remained stable (18–19%) while overall HAP mortality decreased from 1.05 to 0.34/1000 admissions (4.37 to 1.24 /100,000 members) (Figure 1 and 2). Carbapenem, quinolone, aminoglycoside and vancomycin use all decreased significantly (Figure 3). Benzodiazepine use decreased from 10.4% of all inpatient-days in 2014 to 8.8% of inpatient-days in 2016.ConclusionHAP rates, mortality and broad-spectrum antibiotic use were all reduced significantly, despite the absence of clinical practice guidelines or strong supportive literature for guidance. Some interventions had limited support, but most augmented basic nursing care. None had risks of adverse consequences. This supports the need to examine practices to improve care despite absent literature and even more so supports a need to study these difficult nebulous areas of care. Disclosures All authors: No reported disclosures.

Diffusion of Excellence: Accelerating the Spread of Clinical Innovation and Best Practices across the Nation's Largest Health System.

The time it takes for clinical innovation and evidence-based practices to reach patients remains a major challenge for the health care sector. In 2015, the Veterans Health Administration (VHA) launched the Diffusion of Excellence Initiative aimed at aligning organizational resources with early-stage to midstage promising practices and innovations to replicate, scale, and eventually spread those with greatest potential for impact and positive outcomes. Using a 5-step systematic approach refined over time, frontline VHA staff have submitted more than 1676 practices since the initiative's inception, 47 of which have been selected as high-impact, Gold Status practices. These Gold Status practices have been replicated more than 412 times in Veterans Affairs hospitals across the country, improving care for more than 100,000 veterans and approximately $22.6 million in cost avoidance for the VHA. More importantly, practices such as Project HAPPEN (Hospital-Acquired Pneumonia Prevention by Engaging Nurses to complete oral care) and rapid availability of intranasal naloxone have saved veterans' lives. Several practices are now being implemented across the country, and the Diffusion of Excellence Initiative is playing a pivotal role as the VHA works to modernize its health care system. This initiative serves as a promising model for other health care systems seeking to accelerate the spread and adoption of clinical innovation and evidence-based practices.

Prevention of hospital-acquired pneumonia.

Hospital-acquired pneumonia (HAP) is the leading cause of death from hospital-acquired infection. Little work has been done on strategies for prevention of HAP. This review aims to describe potential HAP prevention strategies and the evidence supporting them. Oral care and aspiration precautions may attenuate some risk for HAP. Oral and digestive decontamination with antibiotics may be effective but could increase risk for resistant organisms. Other preventive measures, including isolation practices, remain theoretical or experimental. Hospital-acquired pneumonia occurs because of pharyngeal colonization with pathogenic organisms and subsequent aspiration of these pathogens. Most potential HAP prevention strategies remain unproven.

Prevention of Ventilator-Associated and Early Postoperative Pneumonia Through Tapered Endotracheal Tube Cuffs: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Microaspiration of subglottic secretions is considered a major pathogenic mechanism of hospital-acquired pneumonia, either early postoperative or ventilator-associated pneumonia. Tapered endotracheal tube cuffs have been proposed to provide a better seal of the extraluminal airway, thereby preventing microaspiration and possibly hospital-acquired pneumonia. We performed a systematic review and meta-analysis to assess the value of endotracheal tubes with tapered cuffs in the prevention of hospital-acquired pneumonia. A systematic search of MEDLINE, EMBASE, CENTRAL/CCTR, ClinicalTrials.gov, and ICTRP was conducted up to March 2017. Eligible trials were randomized controlled clinical trials comparing the impact of tapered cuffs versus standard cuffs on hospital-acquired pneumonia. Random-effects meta-analysis calculated odds ratio and 95% CI for hospital-acquired pneumonia occurrence rate between groups. Secondary outcome measures included mortality, duration of mechanical ventilation, length of hospital and ICU stay, and cuff underinflation. Six randomized controlled clinical trials with 1,324 patients from intensive care and postoperative wards were included. Only two studies concomitantly applied subglottic secretion drainage, and no trial performed continuous cuff pressure monitoring. No significant difference in hospital-acquired pneumonia incidence per patient was found when tapered cuffs were compared with standard cuffs (odds ratio, 0.97; 95% CI, [0.73-1.28]; p = 0.81). There were likewise no differences in secondary outcomes. Application of tapered endotracheal tube cuffs did not reduce hospital-acquired pneumonia incidence among ICU and postoperative patients. Further research should examine the impact of concomitant use of tapered cuffs with continuous cuff pressure monitoring and subglottic secretion drainage.

Abstract TP387: Hospital-Acquired Pneumonia Prevention Program to Minimize the Risk for Aspiration Pneumonia in Stroke Survivors

Background: Aspiration pneumonia is one of the leading causes of post stroke morbidity. It increases length of stay, rehabilitation period, readmission rates and mortality. Retrospective chart review at Kaiser Permanente, Woodland Hills indicated that hospital-acquired infections were the leading cause of harm in patient deaths. Of these deaths, hospital-acquired pneumonia (HAP) was the leading contributor. HAPs account for 5% of our hospital’s total pneumonia admissions. Objective: We aimed to implement a simple, multidisciplinary Hospital-Acquired Pneumonia Prevention (HAPP) program in one of our stroke units, which had the highest incidence of HAPs, thus improving our stroke recovery and outcome. Method: We analyzed data in a 15-month period, from January 2015 - April 2016, and determined our baseline data for HAP incidence. Data were separated based on nursing units. The stroke units had the highest incidences of HAPs, accounting for 50% of cases (53 out of 102 cases) in the hospital. We selected the stroke unit with the highest incidence to implement the HAPP program. Patients who were at risk for HAPs were identified using the following: Age ≥ 65, history of or actual aspiration, malnutrition, parenteral tube presence, chronic obstructive pulmonary disease, smoking, ventilator use and post-surgery. Once the patient had been identified as at risk for HAP, the HAPP bundle was implemented. The HAPP bundle included head of bed &gt; 30 ° at all times, up and out of bed for all meals, oral care using chlorhexidine rinse, ambulate at least twice per day, bedside incentive spirometry use and patient/family education. Results: After 3 months of HAPP program implementation there was a significant reduction of HAPs when compared to the same time period the previous year. In 4thQtr 2015, we had 8 HAPs, in 4thQtr 2016 after HAPP program implementation, we had 0 HAP on our targeted stroke unit. Conclusion: Based on our 3 month data, the HAPP program is effective in preventing HAPs. However, we would need to further look at data over a longer period to determine the success of the bundle in preventing HAPs. We also would be spreading this practice throughout all the nursing units within our hospital and eventually to the rest of our hospital system within the Southern California Region.

Spreading the News: Prevention of Hospital-Acquired Pneumonia is Possible

Spreading the News: Prevention of Hospital-Acquired Pneumonia is Possible

Atrial Fibrillation Is an Independent Risk Factor for Hospital-Acquired Pneumonia.

BackgroundPatients who were hospitalized for community-based pneumonia frequently had pre-existing atrial fibrillation (AF) and had subsequent cardiovascular complications. Whether patients who had AF would be susceptible to the development of hospital-acquired pneumonia (HAP) is a serious concern but this has not been investigated. In our clinics, we have made empirical observation of such susceptibility.ObjectivesTo investigate the association between newly developed HAP and pre-existing AF, and to identify whether AF is an independent risk factor for HAP.MethodsHospital data from 8657 sequentially admitted inpatients [1059 patients with AF and 7598 without AF (NAF)] were collected from the Department of Cardiology, First Affiliated Hospital of Shantou University Medical College, Shantou, China, from January 1, 2009 to December 31, 2011. Exclusion criteria were: having previous or current pneumonia, pacemakers, sick sinus syndrome and repeated hospitalization. The incidence of HAP (within 48 hours after hospitalization) was identified among all the patients.ResultsAmong the AF patients, 274 had HAP (adjusted rate 25.64%) which was significantly higher than the 276 NAF patients who had HAP (adjusted rate 3.66%; P<0.001). The increased risk was also associated with high blood pressure, heart failure and age, but not with gender, smoking, coronary heart disease, diabetes, congenital heart disease. In addition, our multiple regression analysis indicates that AF is an independent risk factor for HAP.ConclusionWe have identified, for the first time, that AF is an important risk factor for HAP. Although additional clinical confirmation is needed, our data provide valuable evidence for use in prevention of HAP which is the most common cause of death from nosocomial infection.

Analysis on risk factors of hospital-acquired pneumonia based on expert questionnaire

Objective To explore the risk factors of hospital-acquired pneumonia from the point of view of experts′ experiences with the method of expert questionnaire. Methods The questionnaire on the risk factors of hospital-acquired pneumonia, which was made based on the literature consultation and group discussion, were distributed to 210 experts selected from the whole city. The degree of mean, the coefficient of variation (CV) and the cumulative percent of the risk factors were surveyed. Results The survey distributed 210 cases of questionnaires in all. The effective retrieving rate was 96.2%. The mean value of degree of mean, the cumulative percent and CV were 3.80, 86.7% and 0.30 respectively. Male, aerosol inhalation, low hemoglobin production and cognitive disorder were excluded, according to the discussed criteria. The resting 27 items were considered as the risk factors of hospital acquired pneumonia. Conclusions This study determines the risk factors of hospital-acquired pneumonia by conducting expert questionnaire, which can be a complementary solution to previous retrospective case control study and afford the foundation to further prevention of hospital-acquired pneumonia. Key words: Risk factors; Hospital-acquired pneumonia; Expert Questionnaire

Neumonía nosocomial

The hospital acquired pneumonia (HAP) is one of the most common infections acquired among hospitalised patients. Within the HAP, the ventilator-associated pneumonia (VAP) is the most common nosocomial infection complication among patients with acute respiratory failure. The VAP and HAP are associated with increased mortality and increased hospital costs. The rise in HAP due to antibiotic-resistant bacteria also causes an increase in the incidence of inappropriate empirical antibiotic therapy, with an associated increased risk of hospital mortality. It is very important to know the most common organisms responsible for these infections in each hospital and each Intensive Care Unit, as well as their antimicrobial susceptibility patterns, in order to reduce the incidence of inappropriate antibiotic therapy and improve the prognosis of patients. Additionally, clinical strategies aimed at the prevention of HAP and VAP should be employed in hospital settings caring for patients at risk for these infections.

Prevention of hospital-acquired pneumonia with Yupingfeng Powder in patients with acute cerebral vascular diseases: a randomized controlled trial

An increase in the incidence rate of hospital-acquired pneumonia (HAP) has a direct influence on prognosis and survival of patients with acute cerebral vascular diseases (ACVD), and how to prevent HAP is a growing concern to clinicians. To study the efficacy of Yupingfeng Powder, a compound traditional Chinese herbal medicine, in preventing HAP in patients with ACVD. Sixty ACVD patients with lung qi deficiency syndrome without concurrent infections were randomly divided into prevention group (28 cases) and control group (32 cases). The 60 cases were all from Shanghai Yueyang Hospital of Integrated Traditional Chinese and Western Medicine. Tough measures were taken to prevent cross-infection based on treatment of the primary diseases, well nutrition and support therapy. Yupingfeng Powder was used in the prevention group to prevent HAP. The patients were treated for 10 days. The clinical symptoms, physical signs, body temperature, and chest X-ray were observed. The changes of blood immunoglobulin A (IgA), immunoglobulin G (IgG), immunoglobulin M (IgM) and interleukin-6 (IL-6) were detected before and after treatment. The total response rate in the prevention group was higher than that in the control group (P<0.05), and the total response rates were 78.57% (22/28) and 31.25% (10/32) respectively. The incidence rate of HAP in the prevention group was lower than that in the control group. There were no significant differences in white blood cell count, neutrophilic granulocyte count, and the levels of IgA, IgG, IgM and IL-6 between the two groups before treatment. The white blood cell count and neutrophilic granulocyte count in the control group increased after treatment, and there was a significant difference between the two groups (P<0.05). There was no significant difference in IgA level in the two groups after treatment, and the IgM levels in the two groups were higher than those before treatment (P<0.05), however there was no significant difference in IgM level between the two groups. In the prevention group, there were significant differences in values of IgG and IL-6 between before and after treatment (P<0.01), and after treatment there were differences in values of IgG and IL-6 between the two groups (P<0.05). Yupingfeng Powder has a good clinical effect in prevention of HAP in patients with ACVD, and it can improve the immunological function and relieve the lung qi deficiency symptoms. So the prevention effect of Yupingfeng Powder on HAP is worth being further investigated.

Hospital-acquired pneumonia in Europe

The appropriate management and prevention of hospital-acquired pneumonia (HAP) remain major medical challenges. Much work has been done in this field in the last two decades, which has been constantly summarised in several extensive reviews 1–6. Unsurprisingly, many issues regarding diagnosis, treatment and prevention of HAP continue to be highly controversial. Some issues have recently only begun to attract the attention they deserve, e.g. the impact of distinct surgical settings and the relationship between tracheostomy and pneumonia, as well as bronchitis and pneumonia. Finally, the alarming worldwide increase in microbial resistance forces us to redefine strategies of targeted and effective antimicrobial treatment 7. A mainstay of progress was the release of the American Thoracic Society (ATS) guidelines in 1996 8, which were updated as ATS/Infectious Diseases Society of America (IDSA) guidelines in 2005 9. These guidelines were the first to cover a wide range of issues related to HAP and ventilator-associated pneumonia (VAP), providing a clinically useful framework for the establishment of local diagnostic, therapeutic and preventive strategies 10. Several European experts were also asked to join the committee, resulting in a balanced statement regarding American and European views. As a result, the guidelines also turned into a major reference and framework for ongoing investigation. It is mainly for these reasons that in contrast to community-acquired pneumonia 11, European guidelines for HAP and …

Aerosolised Antibacterials for the Prevention and Treatment of Hospital-Acquired Pneumonia

Aerosolised administration of antibacterials remains theoretically attractive for the prevention and treatment of hospital-acquired pneumonia (HAP) because of the ability to generate high drug concentrations at the site of infection. There is renewed interest in this area because of the shortcomings of current therapies and increasing multidrug resistance in Gram-negative organisms. Clinical trials of aerosolised or endotracheally administered antibacterials for HAP prevention have generally been positive; however, early trials were hampered by the development of resistance related to indiscriminate use. More recent trials have shown efficacy at HAP prevention without adverse effects on microflora as a result of more limited usage. However, prophylactic aerosolised antibacterials still need to be studied in large randomised trials before they could enter widespread use. The treatment of HAP with aerosolised antibacterials has mostly been reported in case series without control groups. Both early reports with aminoglycosides and the more recent use of colistin have reported very good response rates; even with organisms such as Pseudomonas aeruginosa and Acinetobacter baumannii. Aerosolised antibacterials were almost always added to intravenous therapy. On the basis of these reports, the current HAP guidelines allow the addition of aerosolised antibacterials in selected patients with multidrug-resistant organisms. This seems to be a reasonable recommendation until large trials are performed. Overall, toxicity was relatively low in the publications reviewed. Aerosolised drug administration in mechanically ventilated patients requires attention to a number of factors in order to maximise drug deposition in the lung.

What is healthcare-associated pneumonia, and how should it be treated?

In contrast to patients at risk for hospital-acquired pneumonia or mechanically ventilated patients at risk for ventilator-associated pneumonia, healthcare-associated pneumonia is a relatively new clinical entity that includes a spectrum of adult patients who have close association with acute care hospitals or reside in chronic care settings that increase their risk for pneumonia caused by multi-drug-resistant bacteria. Multi-drug-resistant pathogens include methicillin-resistant Staphylococcus aureus and Gram-negative bacilli, such as Pseudomonas aeruginosa, extended-spectrum beta-lactamase-producing Klebsiella pneumoniae, and Acinetobacter species. New guidelines for the management and prevention of hospital-acquired pneumonia, ventilator-associated pneumonia and healthcare-associated pneumonia from the American Thoracic Society and the Infectious Diseases Society of America were published in 2005 and are highlighted in this article. Recent data indicate that types of multi-drug-resistant pathogens may vary in different healthcare settings, and that individuals infected with multi-drug-resistant pathogens are more likely to receive inappropriate initial antibiotic therapy, which may result in poorer outcomes in terms of patient morbidity, mortality and increased length of hospital stay. This review highlights key points in the new recommendations and principles for initiating, de-escalating and stopping antibiotic therapy in individuals with healthcare-associated pneumonia. Widespread implementation of these guidelines is needed in healthcare institutions in order to reduce patient morbidity, mortality, and healthcare costs.