Not Found
Locations

Find information on medical topics, symptoms, drugs, procedures, news and more, written for the health care professional.

Dr. Sanjay Sethi

Shifting Guidelines Concerning Hospital-Acquired Pneumonia—Commentary

12/15/2017 Sanjay Sethi, MD, Professor and Chief, Pulmonary, Critical Care and Sleep Medicine, and Assistant Vice President for Health Sciences, University at Buffalo SUNY

The Infectious Diseases Society of America (IDSA) and American Thoracic Society’s most recent guidelines for management of adults with hospital-acquired pneumonia (HAP) and ventilator-acquired pneumonia (VAP) include notable changes physicians should be aware of. As these categorizations and treatment strategies shift, physicians should also be prepared to have conversations with patients about HAP and its causes and treatments.

Perhaps the most notable change in the 2016 IDSA guidelines is the removal of patients with healthcare-associated pneumonia (HCAP) from the set of those who should be managed according to the guidelines for HAP. HCAP includes patients who were hospitalized in an acute care hospital for two or more days within 90 days of the infection; resided in a nursing home or long-term care facility; received recent intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection; or attended a hospital or hemodialysis clinic.

IDSA points to increasing research that suggests these patient groups are not at such high risk for multi-drug resistant (MDR) pathogens that they need to be managed according to guidelines for hospitalized patients, who are at much higher risk. It is emphasized that underlying patient characteristics are the most important factors to consider when evaluating risk for MDR pathogens in patients who have had interaction with the health care system. 

The IDSA suggested HCAP may remain as a separate clinical entity, but its management will be covered in the upcoming community-acquired pneumonia (CAP) guidelines rather than the 2016 guidelines covering HAP and VAP. Practitioners should familiarize themselves with the full update to the IDSA guidelines on HAP and VAP.

IDSA calls for antibiograms

The updated guidelines also call for hospitals to develop and post antibiograms based upon local pathogens associated with HAP and their antimicrobial susceptibilities. These antibiograms should be used to guide treatment strategies and selection of empiric antibiotic regimens. Specifically, physicians should limit the use of a broad antibiotic regimen when possible, including decreasing the unnecessary use of dual gram-negative and empiric methicillin-resistant Staphylococcus aureus (MRSA) antibiotic treatment.

Given that likely HAP pathogens require initial empiric antibiotic therapy that is active against antibiotic-resistant organisms, it’s crucial to reassess patients 2 to 3 days after initiation of treatment and change antibiotics based on available culture and clinical data.

Discussing HAP with patients

Patients may not understand key differences between HAP and CAP, including the fact that HAP is usually caused by a bacterial infection. In some cases, they may assume what they know about CAP applies to their HAP.

It’s crucial for doctors and healthcare professionals to explain that HAP is a distinctly different condition. Practitioners should stress the following aspects of HAP when talking to patients:

  • HAP is a common complication of hospitalization. In fact, pneumonia is the most common major site of infection, according to the Center for Disease Control’s HAI Estimates Occurring in US Acute Care Hospitals, 2011.
  • The illness that led to the hospitalization predisposes the patient to develop pneumonia. The severity of the underlying illness is a risk factor. Patients who develop HAP tend to be older with simultaneous health problems including stroke, heart failure or diabetes.
  • HAP is generally more difficult to treat than CAP. Patients may not realize that the bacteria causing infections in a hospital are different than the bacteria in the community. Hospital-acquired pathogens are often drug-resistant, making treatment of HAP more difficult.
HAP is rarely contagious. It’s highly unlikely that a healthy person outside the hospital would “catch” the pathogen causing HAP. For additional information and education, physicians can refer patients to the discussion of HAP and HCAP in the consumer version of the Manuals to give them a more accurate understanding of the infection and how it differs from pneumonia acquired in the community. 
Dr. Sanjay Sethi

Shifting Guidelines Concerning Hospital-Acquired Pneumonia—Commentary

12/15/2017 Sanjay Sethi, MD, Professor and Chief, Pulmonary, Critical Care and Sleep Medicine, and Assistant Vice President for Health Sciences, University at Buffalo SUNY

The Infectious Diseases Society of America (IDSA) and American Thoracic Society’s most recent guidelines for management of adults with hospital-acquired pneumonia (HAP) and ventilator-acquired pneumonia (VAP) include notable changes physicians should be aware of. As these categorizations and treatment strategies shift, physicians should also be prepared to have conversations with patients about HAP and its causes and treatments.

Perhaps the most notable change in the 2016 IDSA guidelines is the removal of patients with healthcare-associated pneumonia (HCAP) from the set of those who should be managed according to the guidelines for HAP. HCAP includes patients who were hospitalized in an acute care hospital for two or more days within 90 days of the infection; resided in a nursing home or long-term care facility; received recent intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection; or attended a hospital or hemodialysis clinic.

IDSA points to increasing research that suggests these patient groups are not at such high risk for multi-drug resistant (MDR) pathogens that they need to be managed according to guidelines for hospitalized patients, who are at much higher risk. It is emphasized that underlying patient characteristics are the most important factors to consider when evaluating risk for MDR pathogens in patients who have had interaction with the health care system. 

The IDSA suggested HCAP may remain as a separate clinical entity, but its management will be covered in the upcoming community-acquired pneumonia (CAP) guidelines rather than the 2016 guidelines covering HAP and VAP. Practitioners should familiarize themselves with the full update to the IDSA guidelines on HAP and VAP.

IDSA calls for antibiograms

The updated guidelines also call for hospitals to develop and post antibiograms based upon local pathogens associated with HAP and their antimicrobial susceptibilities. These antibiograms should be used to guide treatment strategies and selection of empiric antibiotic regimens. Specifically, physicians should limit the use of a broad antibiotic regimen when possible, including decreasing the unnecessary use of dual gram-negative and empiric methicillin-resistant Staphylococcus aureus (MRSA) antibiotic treatment.

Given that likely HAP pathogens require initial empiric antibiotic therapy that is active against antibiotic-resistant organisms, it’s crucial to reassess patients 2 to 3 days after initiation of treatment and change antibiotics based on available culture and clinical data.

Discussing HAP with patients

Patients may not understand key differences between HAP and CAP, including the fact that HAP is usually caused by a bacterial infection. In some cases, they may assume what they know about CAP applies to their HAP.

It’s crucial for doctors and healthcare professionals to explain that HAP is a distinctly different condition. Practitioners should stress the following aspects of HAP when talking to patients:

  • HAP is a common complication of hospitalization. In fact, pneumonia is the most common major site of infection, according to the Center for Disease Control’s HAI Estimates Occurring in US Acute Care Hospitals, 2011.
  • The illness that led to the hospitalization predisposes the patient to develop pneumonia. The severity of the underlying illness is a risk factor. Patients who develop HAP tend to be older with simultaneous health problems including stroke, heart failure or diabetes.
  • HAP is generally more difficult to treat than CAP. Patients may not realize that the bacteria causing infections in a hospital are different than the bacteria in the community. Hospital-acquired pathogens are often drug-resistant, making treatment of HAP more difficult.
HAP is rarely contagious. It’s highly unlikely that a healthy person outside the hospital would “catch” the pathogen causing HAP. For additional information and education, physicians can refer patients to the discussion of HAP and HCAP in the consumer version of the Manuals to give them a more accurate understanding of the infection and how it differs from pneumonia acquired in the community.