eMedicine Specialties > Infectious Diseases > Lower Respiratory Tract Infections

Nosocomial Pneumonia: Follow-up

Author: Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Contributor Information and Disclosures

Updated: May 28, 2009

Follow-up

Further Inpatient Care

  • Patients with nosocomial pneumonia (NP; also known as hospital-acquired pneumonia [HAP] or health care–associated pneumonia [HCAP]) should be transferred to the ICU if they are on the general medical wards and cannot be maintained without ventilatory support.
  • Patients in the ICU may require ventilatory support, depending on their respiratory status.

Deterrence/Prevention

  • Beds that permit some degree of patient turning may decrease the risk of nosocomial pneumonia in at-risk patients.

Complications

  • The list of differential diagnoses represents the main clinical problem in nosocomial pneumonia. Many conditions mimic the presentation of nosocomial pneumonia. For example, any disorder that results in leukocytosis with variable degrees of left shift may be included in the differential diagnoses. An inflammatory or infectious process can cause fever; therefore, do not regard this symptom as an indication of an infectious disease process. Many conditions other than nosocomial pneumonia can cause pulmonary infiltrates. Consider all of these differential diagnoses carefully before settling on a diagnosis and embarking on a course of antimicrobial therapy.
  • Failure to successfully wean the patient from the respirator (possibly because of lack of cardiopulmonary function or a superimposed process [eg, HSV-1 pneumonitis]) is a common problem following intubation for nosocomial pneumonia.
  • HSV-1 pneumonitis develops in intubated patients who have unchanging or persistent pulmonary infiltrates after 2 weeks of antimicrobial therapy. These patients usually have low-grade fevers with variable degrees of leukocytosis. Demonstrating HSV-1 in samples of respiratory secretions may establish the diagnosis.
  • Start treatment with acyclovir in patients diagnosed with HSV-1 infection; acyclovir decreases hypoxemia and subsequently permits weaning of the patient from the respirator.

Prognosis

  • The prognosis in patients with nosocomial pneumonia depends on preexisting underlying cardiopulmonary function and host defenses.

Miscellaneous

Medicolegal Pitfalls

  • Failure to direct empiric monotherapy against P aeruginosa, ensuring coverage against all other bacteriologic causes of nosocomial pneumonia (NP; also known as hospital-acquired pneumonia [HAP] or health care–associated pneumonia [HCAP])
  • Failure to consider the numerous conditions that mimic nosocomial pneumonia, many of which are treatable and reversible disorders
  • Failure to consider the most common conditions that mimic nosocomial pneumonia, which include pulmonary hemorrhage, pulmonary embolus, and congestive heart failure
  • Failure to suspect ARDS, which is usually readily diagnosable according to the microatelectatic changes on the chest radiograph and the progressive and severe hypoxemia indicated by the ABG levels (Little or no fever may accompany these symptoms.)

Special Concerns

  • Compromised cardiac and lung function may further decrease the cardiopulmonary reserve of pneumonia, accounting for the high mortality and morbidity rates associated with nosocomial pneumonia.
  • Barotrauma may decrease an already compromised lung function and alter chest radiographic appearances.
 


More on Nosocomial Pneumonia

Overview: Nosocomial Pneumonia
Differential Diagnoses & Workup: Nosocomial Pneumonia
Treatment & Medication: Nosocomial Pneumonia
Follow-up: Nosocomial Pneumonia
Multimedia: Nosocomial Pneumonia
References
[ CLOSE WINDOW ]

References

  1. Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA. May 27 2009;301(20):2120-8. [Medline]. [Full Text].

  2. American Thoracic Society and the Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. Feb 15 2005;171(4):388-416. [Medline]. [Full Text].

  3. Agodi A, Barchitta M, Cipresso R, et al. Pseudomonas aeruginosa carriage, colonization, and infection in ICU patients. Intensive Care Med. Jul 2007;33(7):1155-61. [Medline].

  4. Alp E, Guven M, Yildiz O, et al. Incidence, risk factors and mortality of nosocomial pneumonia in intensive care units: a prospective study. Ann Clin Microbiol Antimicrob. Sep 15 2004;3:17. [Medline].

  5. Bartlett JG, O'Keefe P, Tally FP, et al. Bacteriology of hospital-acquired pneumonia. Arch Intern Med. May 1986;146(5):868-71. [Medline].

  6. Bates JH, Campbell GD, Barron AL, et al. Microbial etiology of acute pneumonia in hospitalized patients. Chest. Apr 1992;101(4):1005-12. [Medline].

  7. Beck KD, Gastmeier P. Clinical or epidemiologic diagnosis of nosocomial pneumonia: is there any difference?. Am J Infect Control. Oct 2003;31(6):331-5. [Medline].

  8. Bergmans DC, Bonten MJ, van Tiel FH, et al. Cross-colonisation with Pseudomonas aeruginosa of patients in an intensive care unit. Thorax. Dec 1998;53(12):1053-8. [Medline].

  9. Bonten MJ, Gaillard CA, Wouters EF, et al. Problems in diagnosing nosocomial pneumonia in mechanically ventilated patients: a review. Crit Care Med. Oct 1994;22(10):1683-91. [Medline].

  10. Bonten MJM, Bergmans DC. Nosocomial pneumonia. In: Mayhall CG, ed. Hospital Epidemiology and Infection Control. 2nd ed. Lippincott, Williams, and Wilkins; 1999:211-38.

  11. Bouza E, Torres MV, Radice C, et al. Direct E-test (AB Biodisk) of respiratory samples improves antimicrobial use in ventilator-associated pneumonia. Clin Infect Dis. Feb 1 2007;44(3):382-7. [Medline].

  12. Brown EM. Empirical antimicrobial therapy of mechanically ventilated patients with nosocomial pneumonia. J Antimicrob Chemother. Oct 1997;40(4):463-8. [Medline].

  13. Campbell GD, SanPedro GS, Bartelt MA, et al. Comparison of acridine orange stain with culture and gram stain of needle aspirate in experimental Pseudomonas pneumonia. Am Rev Respir Dis. Oct 1991;144(4):959-61. [Medline].

  14. Chastre J, Fagon JY. Invasive diagnostic testing should be routinely used to manage ventilated patients with suspected pneumonia. Am J Respir Crit Care Med. Aug 1994;150(2):570-4. [Medline].

  15. Chastre J, Wolff M, Fagon JY, et al. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA. Nov 19 2003;290(19):2588-98. [Medline].

  16. Craig CP, Connelly S. Effect of intensive care unit nosocomial pneumonia on duration of stay and mortality. Am J Infect Control. Aug 1984;12(4):233-8. [Medline].

  17. Craven DE, Steger KA. Hospital-acquired pneumonia: perspectives for the healthcare epidemiologist. Infect Control Hosp Epidemiol. Nov 1997;18(11):783-95. [Medline].

  18. Crowe HM. Nosocomial pneumonia: problems and progress. Heart Lung. Sep-Oct 1996;25(5):418-21. [Medline].

  19. Cunha BA. Antibiotic selection is crucial for optimal empiric monotherapy of ventilator-associated pneumonia. Crit Care Med. Aug 2007;35(8):1992-4. [Medline].

  20. Cunha BA. Monotherapy for nosocomial pneumonias. Antibiot Clin. 1998;2:34-7.

  21. Cunha BA. Multi-drug Resistant (MDR) Klebsiella, Acinetobacter, and Pseudomonas aeruginosa. Antibiotics for Clinicians. 2006;10:354-355.

  22. Cunha BA. Nosocomial pneumonia. Diagnostic and therapeutic considerations. Med Clin North Am. Jan 2001;85(1):79-114. [Medline].

  23. Cunha BA. Pneumonia Essentials. 2nd ed. Royal Oak, Michigan: Physicians Press; 2008.

  24. Cunha BA. S. aureus Nosocomial Pneumonia: Clinical Aspects. Infectious Disease Practice. 2007;31:557-560.

  25. Cunha BA. The antibiotic treatment of community-acquired, atypical, and nosocomial pneumonias. Med Clin North Am. May 1995;79(3):581-97. [Medline].

  26. Cunha BA. Ventilator-associated pneumonia: monotherapy is optimal if chosen wisely. Crit Care. 2006;10(2):141. [Medline].

  27. Cunha BA, ed. Fever in the critical care unit. In: Infectious Diseases in Critical Care Medicine. New York, NY: Marcel Dekker; 1998:1-16.

  28. De Rosa FG, Craven DE. Ventilator-associated pneumonia: Current management strategies. Infect Med. 2003;20:248-259.

  29. Ferrara AM. Potentially multidrug-resistant non-fermentative Gram-negative pathogens causing nosocomial pneumonia. Int J Antimicrob Agents. Mar 2006;27(3):183-95. [Medline].

  30. Freeman R, McPeake PK. Acquisition, spread, and control of Pseudomonas aeruginosa in a cardiothoracic intensive care unit. Thorax. Oct 1982;37(10):732-6. [Medline].

  31. Furtado GH, d'Azevedo PA, Santos AF, et al. Intravenous polymyxin B for the treatment of nosocomial pneumonia caused by multidrug-resistant Pseudomonas aeruginosa. Int J Antimicrob Agents. Oct 2007;30(4):315-9. [Medline].

  32. Garner JS, Jarvis WR, Emori TG, et al. CDC definitions for nosocomial infections, 1988. Am J Infect Control. Jun 1988;16(3):128-40. [Medline].

  33. Go J, Cunha BA. Acinetobacter baumanii: Infection control implications. Infect Dis Pract. 1999;23:65-8.

  34. Graybill JR, Marshall LW, Charache P, et al. Nosocomial pneumonia. A continuing major problem. Am Rev Respir Dis. Nov 1973;108(5):1130-40. [Medline].

  35. Gusmao ME, Dourado I, Fiaccone RL. Nosocomial pneumonia in the intensive care unit of a Brazilian university hospital: an analysis of the time span from admission to disease onset. Am J Infect Control. Jun 2004;32(4):209-14. [Medline].

  36. Iannini PB, Claffey T, Quintiliani R. Bacteremic Pseudomonas pneumonia. JAMA. Oct 28 1974;230(4):558-61. [Medline].

  37. Johanson WG, Pierce AK, Sanford JP. Changing pharyngeal bacterial flora of hospitalized patients. Emergence of gram-negative bacilli. N Engl J Med. Nov 20 1969;281(21):1137-40. [Medline].

  38. Johnson DH, Klein NC, Cunha BA. Postoperative Serratia marcescens endophthalmitis. Heart Lung. May 1992;21(3):300-2. [Medline].

  39. Joshi M, Metzler M, McCarthy M, et al. Comparison of piperacillin/tazobactam and imipenem/cilastatin, both in combination with tobramycin, administered every 6h for treatment of nosocomial pneumonia. Respir Med. Feb 15 2006;[Medline].

  40. Kirby BD, Snyder KM, Meyer RD, Finegold SM. Legionnaires' disease: report of sixty-five nosocomially acquired cases of review of the literature. Medicine (Baltimore). May 1980;59(3):188-205. [Medline].

  41. Klompas M. Does this patient have ventilator-associated pneumonia?. JAMA. Apr 11 2007;297(14):1583-93. [Medline].

  42. LaForce FM. Hospital-acquired gram-negative rod pneumonias: an overview. Am J Med. Mar 1981;70(3):664-9. [Medline].

  43. Lerner AM, Tillotson JR. Pneumonias caused by gram-negative bacilli. Mich Med. Jan 1968;67(1):35-8. [Medline].

  44. Louria DB, Kaminski T. The effects of four antimicrobial drug regimens on sputum superinfection in hospitalized patients. Am Rev Respir Dis. May 1962;85:649-65. [Medline].

  45. Manhold C, von Rolbicki U, Brase R, et al. Outbreaks of Staphylococcus aureus infections during treatment of late onset pneumonia with ciprofloxacin in a prospective, randomized study. Intensive Care Med. Dec 1998;24(12):1327-30. [Medline].

  46. Mason CM, Nelson S, Summer WR. Bacterial colonization: Pathogenesis and clinical significance. Immunol Allergy Clin North Am. 1993;13:93-108.

  47. Mayhall CG. Nosocomial pneumonia. Diagnosis and prevention. Infect Dis Clin North Am. Jun 1997;11(2):427-57. [Medline].

  48. Meduri GU. Diagnosis of ventilator-associated pneumonia. Infect Dis Clin North Am. Jun 1993;7(2):295-329. [Medline].

  49. Meduri GU, Mauldin GL, Wunderink RG, et al. Causes of fever and pulmonary densities in patients with clinical manifestations of ventilator-associated pneumonia. Chest. Jul 1994;106(1):221-35. [Medline].

  50. Mesaros N, Nordmann P, Plesiat P, et al. Pseudomonas aeruginosa: resistance and therapeutic options at the turn of the new millennium. Clin Microbiol Infect. Jun 2007;13(6):560-78. [Medline].

  51. Pennington JE. Nosocomial pneumonias. Curr Opin Infec Dis. 1992;5:505-11.

  52. Pennington JE. Pseudomonas aeruginosa pneumonia and other respiratory tract infections. In: Batch A, Smith RP, eds. Pseudomonas Aeruginosa: Infections and Treatment. Marcel Dekker; 1995:159-81.

  53. Pennington JE, Reynolds HY, Carbone PP. Pseudomonas pneumonia. A retrospective study of 36 cases. Am J Med. Aug 1973;55(2):155-60. [Medline].

  54. Pierce AK, Sanford JP. Aerobic gram-negative bacillary pneumonias. Am Rev Respir Dis. Nov 1974;110(5):647-58. [Medline].

  55. Pittet D, Harbarth S. What techniques for diagnosis of ventilator-associated pneumonia?. Lancet. Jul 11 1998;352(9122):83-4. [Medline].

  56. Robert R, Grollier G, Dore P, et al. Nosocomial pneumonia with isolation of anaerobic bacteria in ICU patients: therapeutic considerations and outcome. J Crit Care. Sep 1999;14(3):114-9. [Medline].

  57. Rose HD, Heckman MG, Unger JD. Pseudomonas aeruginosa pneumonia in adults. Am Rev Respir Dis. Mar 1973;107(3):416-22. [Medline].

  58. Salata RA, Lederman MM, Shlaes DM, et al. Diagnosis of nosocomial pneumonia in intubated, intensive care unit patients. Am Rev Respir Dis. Feb 1987;135(2):426-32. [Medline].

  59. Shlaes DM, Lederman MM, Chmielewski R, et al. Sputum elastin fibers and the diagnosis of necrotizing pneumonia. Chest. Jun 1984;85(6):763-6. [Medline].

  60. Siempos II, Vardakas KZ, Manta KG, Falagas ME. Carbapenems for the treatment of immunocompetent adult patients with nosocomial pneumonia. Eur Respir J. Mar 2007;29(3):548-60. [Medline].

  61. Soto GJ. Diagnostic strategies for nosocomial pneumonia. Curr Opin Pulm Med. May 2007;13(3):186-91. [Medline].

  62. Talon D, Mulin B, Rouget C, et al. Risks and routes for ventilator-associated pneumonia with Pseudomonas aeruginosa. Am J Respir Crit Care Med. Mar 1998;157(3 Pt 1):978-84. [Medline].

  63. Tillotson JR, Lerner AM. Characteristics of nonbacteremic Pseudomonas pneumonia. Ann Intern Med. Feb 1968;68(2):295-307. [Medline].

  64. Wang S, Kwok M, McNamara JK, Cunha BA. Colistin for Multi-Drug Resistant (MDR) Gram-Negative Bacillary Infections. Antibiotics for Clinicians. 2007;11:389-396.

  65. Wenzel RP. Hospital-acquired pneumonia: overview of the current state of the art for prevention and control. Eur J Clin Microbiol Infect Dis. Jan 1989;8(1):56-60. [Medline].

  66. Wenzel RP, Thompson RL, Landry SM, et al. Hospital-acquired infections in intensive care unit patients: an overview with emphasis on epidemics. Infect Control. Sep-Oct 1983;4(5):371-5. [Medline].

  67. Wunderink RG, Woldenberg LS, Zeiss J, et al. The radiologic diagnosis of autopsy-proven ventilator-associated pneumonia. Chest. Feb 1992;101(2):458-63. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

nosocomial pneumonia, NP, hospital-acquired pneumonia, HAP, healthcare-associated pneumonia, health care–associated pneumonia, HCAP, ventilator-associated pneumonia, VAP

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Wesley W Emmons, MD, FACP, Assistant Professor, Department of Medicine, Thomas Jefferson University; Consulting Staff, Infectious Diseases Section, Department of Internal Medicine, Christiana Care, Newark, DE
Wesley W Emmons, MD, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and International AIDS Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Ronald A Greenfield, MD, Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine
Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist  Speaking and teaching

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD, Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Association of Professors of Medicine, Association of Program Directors in Internal Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.