Hospital-acquired pneumonia

Answer 1

Definition

Hospital-acquired pneumonia is an infection of the lungs contracted during a hospital stay.

Alternative Names

Nosocomial pneumonia; Ventilator-associated pneumonia

Causes, incidence, and risk factors

Pneumonia is a very common illness. It is caused by many different germs and can range in seriousness from mild to life-threatening.

Hospital-acquired pneumonia tends to be more serious, because a patient's defense mechanisms against infection are often impaired during a hospital stay. In addition, the types of germs present in a hospital are often more dangerous than those encountered in the community.

Hospital-acquired pneumonia occurs more often in patients who require a respirator (also called a breathing machine or ventilator) to help them breathe. When pneumonia occurs in a patient who is on a ventilator, it is known as ventilator-associated pneumonia.

Risk factors for hospital-acquired pneumonia include:

• Alcoholism
• Being on a breathing machine
• Breathing material into the lungs (aspiration)
• Chest surgery
• Immunosuppression from medications or disease
• Long-term (chronic) lung disease
• Medications that affect alertness
• Older age
• Recent illness

Symptoms

• Cough that may produce mucus-like, greenish, or pus-like phlegm (sputum)
• Chills
• Easy fatigue
• Excessive sweating (rare)
• Fever
• General discomfort, uneasiness, or ill feeling (malaise)
• Headache
• Joint stiffnessand pain (rare)
• Loss of appetite
• Muscle stiffness (rare)
• Nausea and vomiting
• Sharp or stabbing chest pain that gets worse with deep breathing or coughing
• Shortness of breath

Signs and tests

A physical examination shows:

• Respiratory distress
• Crackles or decreased breath sounds when listening to the chest with a stethoscope

Tests performed may include:

• Arterial blood gases
• Blood cultures
• Chest x-ray or CT scan
• Complete blood count (CBC)
• Sputum culture
• Sputum gram stain

Treatment

Treatment aims to cure the infection with antibiotics. An antibiotic is chosen based on the specific germ found by sputum culture.

However, the bacteria cannot always be identified with tests. Antibiotic therapy is given to fight the most common bacteria that infect hospitalized patients -- Staphylococcus aureus and gram-negative bacteria.

Supportive treatment includes:

• Oxygen
• Lung treatments to loosen and remove thick mucus from the lungs

Expectations (prognosis)

Most patients respond to treatment and improve within 2 weeks. However, hospital-acquired pneumonia can be very severe and sometimes life-threatening.

Complications

Elderly or very weak patients who do not respond to treatment may die from acute respiratory failure caused by the pneumonia.

Prevention

Ongoing prevention programs to limit hospital-acquired infections are in place at most institutions.

References

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

Limper AH. Overview of pneumonia. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 97.

Answer 2

Definition

Hospital-acquired pneumonia is an infection of the lungs that occurs during a hospital stay. This type of pneumonia can be very severe. Sometimes it can be fatal.

Alternative Names

Nosocomial pneumonia; Ventilator-associated pneumonia; Health-care associated pneumonia

Causes, incidence, and risk factors

Pneumonia is a common illness. It is caused by many different germs. Hospital-acquired pneumonia tends to be more serious than other lung infections, because:

• Patients in the hospital are often very sick and cannot fight off germs.
• The types of germs present in a hospital are often more dangerous than those encountered in the community.

Hospital-acquired pneumonia occurs more often in patients who are using a respirator machine to help them breathe. This machine is also called a ventilator. This type of pneumonia is known as ventilator-associated pneumonia.

Hospital-acquired pneumonia can also be spread by health care workers, who can pass germs from their hands or clothes from one patient to another. That is why hand-washing, wearing gowns, and using other safety measures is so important in the hospital.

Patients who are more prone to getting hospital-acquired pneumonia include patients who:

• Are alcoholic
• Have had chest surgery or other major surgery
• Have a weak immune system from cancer treatment, certain medicines, or severe wounds
• Have long-term (chronic) lung disease
• Breathe saliva or food into their lungs as a result of not being fully alert or problems swallowing
• Are older

Symptoms

In an elderly person, the first sign of hospital-acquired pneumonia may be mental changes or confusion. Other symptoms are:

• A cough that may produce mucus-like, greenish, or pus-like phlegm (sputum)
• Fever and chills
• General discomfort, uneasiness, or ill feeling (malaise)
• Loss of appetite
• Nausea and vomiting
• Sharp chest pain that gets worse with deep breathing or coughing
• Shortness of breath

Signs and tests

Tests to check for hospital-acquired pneumonia may include:

• Arterial blood gases, to measure oxygen levels in the blood
• Blood cultures, to see if the infection has spread to the blood
• Chest x-ray or CT scan, to check the lungs
• Complete blood count (CBC)
• Pulse oximetry, to measure oxygen levels in the blood
• Sputum cultureor sputum gram stain, to check for what germs are causing the pneumonia

Treatment

You will receive antibiotics through your veins (IV) to treat your lung infection. The antibiotic you are given will fight the germs that are in your sputum culture.

You may also receive oxygen to help you breathe better and lung treatments to loosen and remove thick mucus from your lungs.

Patients who have other serious conditions do not recover as well from pneumonia as patients who are not as sick.

Expectations (prognosis)

Hospital-acquired pneumonia can be a life-threatening illness. Long-term lung damage may occur.

Prevention

Wash your hands for at least 1 minute, like this:

• Lather up well with warm water and soap.
• Wash the backs and palms of your hands, fingers, between your fingers, and under your nails thoroughly.
• Wash for as long as it takes you to slowly say the alphabet or sing the "Happy Birthday" song 2 times through.
• Dry with a clean paper towel. Also, use a paper towel to turn off the faucet and open the bathroom door.

After any surgery, you will be asked to take deep breaths to help keep your lungs open. Follow the advice of your doctor and nurse to help prevent pneumonia.

Most hospitals have programs to prevent hospital-acquired infections.

References

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

Chastre J, Luyt CE. Ventilator-associated pneumonia. In: Mason RJ, Broaddus VC, Martin TR, et al. Murray& Nadel's Textbook of Respiratory Medicine. 5th ed.Philadelphia,Pa: Saunders Elsevier; 2010:chap 33.

Craven DE, Chroneou A. Nosocomial pneumonia. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2009:chap 303.

Fishman N, Calfee DP. Prevention and control of health care-associated infections. In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed.Philadelphia,PA: Saunders Elsevier; 2011:chap 290.

Limper AH. Overview of pneumonia.In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed.Philadelphia,PA: Saunders Elsevier; 2011:chap 97.

Reviewed By

Review Date: 02/26/2012

David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.