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Hospital-Acquired and Health Care–Associated Pneumonia

(Institution-Acquired Pneumonia)

By Sanjay Sethi, MD, Professor and Chief, Pulmonary, Critical Care and Sleep Medicine, and Assistant Vice President for Health Sciences, University at Buffalo SUNY

Hospital-acquired pneumonia develops in people who have been hospitalized, typically after about 2 days or more of hospitalization. Health care–associated pneumonia develops in people who reside in nursing homes or who have contact with medical settings, such as dialysis centers.

  • Many bacteria, viruses, and even fungi can cause pneumonia in people who are hospitalized or have visited medical institutions.

  • The most common symptom is a cough that produces sputum, but chest pain, chills, fever, and shortness of breath are also common.

  • Diagnosis is made by listening to the lungs with a stethoscope and by examining x-rays of the chest.

  • Antibiotics, antiviral drugs, or antifungal drugs are used, depending on which organism has most likely caused the pneumonia.

Pneumonia acquired in the hospital or in another health care setting is usually more severe than pneumonia acquired in the community because the infecting organisms tend to be more aggressive. They are also less likely to respond to antibiotics (called resistance) and are, therefore, harder to treat. Additionally, people in hospitals and nursing homes and those who have contact with medical settings tend to be sicker even without pneumonia than those living in the community and therefore are not as able to fight the infection.


People who are hospitalized and seriously ill, especially if they require assistance in breathing from a breathing machine (mechanical ventilator), are at greatest risk of acquiring pneumonia. Other risk factors include

  • Previous antibiotic treatment

  • Coexisting illness such as heart, lung, liver, or kidney dysfunction

  • Age older than 70

  • Recent abdominal or chest surgery

  • Possibly the use of proton pump inhibitors (omeprazole, esomeprazole, lansoprazole, or pantoprazole) for treatment of gastroesophageal reflux disease

  • Debilitation, particularly among nursing home residents

Organisms that do not normally cause pneumonia in healthy people can cause pneumonia in people who are hospitalized or debilitated. Many such people have an immune system that is not able to resist even mild infectious challenges. The most likely organisms depend on what organisms are prevalent in the hospital and sometimes depend on what other illnesses the person has.

Hospital-acquired pneumonia is more likely than community-acquired pneumonia to be caused by Staphylococcus aureus (particularly methicillin-resistant Staphylococcus aureus [MRSA]) or Pseudomonas aeruginosa and other gram-negative bacteria that normally reside in the digestive tract. Sometimes hospital-acquired pneumonia is caused by Streptococcus pneumoniae, or Legionella.


Symptoms are generally the same as those for community-acquired pneumonia:

  • A general feeling of weakness (malaise)

  • Cough that produces sputum (thick or discolored mucus)

  • Shortness of breath

  • Fever

  • Chills

  • Chest pain

Pneumonia acquired in a health care setting may be more difficult for doctors to recognize than pneumonia acquired in the community. For example, many people in health care settings who develop pneumonia, such as older people, those with breathing tubes who are receiving mechanical ventilation, those with dementia, and those who are critically ill, may be unable to describe symptoms such as chest pain, shortness of breath, and weakness. In those cases pneumonia is often suspected on the basis of fever and an increase in the respiratory rate and the heart rate.

Did You Know...

  • Pneumonia that is acquired in the hospital or another type of health care setting tends to be far more severe than pneumonia acquired in the community.


  • A doctor's evaluation of symptoms

  • A chest x-ray

Hospital-acquired or health care–associated pneumonia is suspected on the basis of a person’s symptoms. The diagnosis is confirmed with a chest x-ray. Blood tests are done. However, these methods are not always accurate.

People may be very sick, so doctors may need to identify the organism that is causing pneumonia in order to determine the best treatment. For these reasons, sometimes doctors use bronchoscopy to confirm pneumonia and obtain a sputum specimen to try to identify the organism. During bronchoscopy, a flexible viewing tube is inserted into the trachea and lungs. Samples of pus, secretions, or even lung tissue can be collected for examination. If no secretions are visible, an area of the lung can be washed with fluid, which can then be retrieved for analysis (a procedure called bronchoalveolar lavage).


  • Antibiotics

Treatment is with antibiotics that are chosen based on which organisms are most likely to be the cause and the specific risk factors the person has. Because of the seriousness of the infection, people who developed pneumonia while in a nursing home are often treated in the hospital. People who are seriously ill may be placed in an intensive care unit and sometimes put on a ventilator. Treatments include intravenous antibiotics, oxygen, and intravenous fluids.

There are several drugs that can be used, including the following:

  • Amikacin

  • Aztreonam

  • Cefepime

  • Ceftazidime

  • Gemifloxacin

  • Imipenem plus cilastatin

  • Levofloxacin

  • Meropenem

  • Moxifloxacin

  • Piperacillin plus tazobactam

  • Tobramycin

These drugs are given alone or are combined with vancomycin if doctors suspect the person may have MRSA.

End-of-life issues in serious pneumonia

Because some people who live in nursing homes are very ill, pneumonia can be extremely serious. In order to treat pneumonia with the most powerful treatments available, doctors usually have nursing home residents transferred to a hospital. However, pneumonia is often fatal despite such treatment, and the treatment itself may be difficult to tolerate, especially if a mechanical ventilator is needed. People who are expected to die soon may not wish to receive such aggressive treatment. People with severe or terminal disorders should discuss with their doctors and family members their wishes for treatment of pneumonia when they enter a nursing home.


Despite receiving excellent treatment, about 25 to 50% of people who develop hospital-acquired pneumonia die. In people who have health care–associated pneumonia, the risk of death depends, in part, on the need for hospitalization. Among people who need to be hospitalized for care, the risk of death is 13 to 41%. The risk is lower among people who do not require hospitalization. Whether the cause of death is due to underlying illness or to the pneumonia itself can be difficult to tell.

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