torres.qxp 11/8/09 3:03 pm Page 59
Pneumonia
Prevention and Treatment of Hospital-acquired Pneumonia
Miquel Ferrer
1
and Antoni Torres
2
1. Consultant Physician; 2. Head, Department of Pneumology, Institute of Thorax, Hospital Clinic,Barcelona
Abstract
Hospital-acquired pneumonia, especially ventilator-associated pneumonia, is a highly frequent infection seen mainly in intensive care units.
Despite advances in our knowledge of the physiopathology, diagnosis and prevention of this disease, mortality continues to be unacceptably
high. The prevention of hospital-acquired pneumonia requires a combination of several actions that include hygienic measures aimed at
reducing cross-infection between patients, avoidance of endotracheal intubation and prolonged mechanical ventilation and modulation of
oropharyngeal flora. In the specific subset of ventilated patients, the prevention of aspiration of contaminated oropharyngeal secretions by
aspiration of subglottic secretions and a semi-recumbent body position are also effective measures. On suspicion of nosocomial pneumonia,
samples of respiratory secretions should be taken for cultures and microbiological studies and an adequate and appropriate empirical
treatment must be started immediately. If necessary, this treatment should include a combination of broad-spectrum antibiotics according
to the characteristics of the patient and the specific epidemiology of the unit. Re-evaluation on the third day is of vital importance; this is the
point at which the antibiotic down-scaling or reduction strategy should be implemented, in agreement with the results of the cultures of the
respiratory secretions. At present, the length of antibiotic treatment seems to be shorter than several years ago and, in general, seven days
of treatment should be sufficient in patients who are not infected by high-risk micro-organisms or in those with a turbid clinical evolution.
Keywords
Hospital-acquired pneumonia, ventilator-associated pneumonia
Disclosure: Miquel Ferrer is on the advisory boards of sanofi-aventis and Covidien. Antoni Torres is on the advisory boards of Astellas and Bayer.
Received: 3 October 2008 Accepted: 11 June 2009
Correspondence: Antoni Torres, Head, Department of Pneumology, Hospital Clinic, IDIBAPS, CibeRes (CB06/06/0028)-ISCIII-MCyT, Villarroel 170, 08036 Barcelona, Spain.
atorres@ub.edu
Prevention of Hospital-acquired Pneumonia • general prophylactic measures;
Owing to the high morbidity and mortality of hospital-acquired • intubation and mechanical ventilation;
pneumonia (HAP), it is necessary to fight the disease in terms of both • aspiration, body position and enteral feeding;
finding effective treatment and reducing the length of time patients • modulation of colonisation by oral antiseptics and antibiotics; and
stay in hospital. To date, many efforts have been made in order to • stress bleeding prophylaxis, transfusion and glucose control.
reach consensus on control measures and prevention of HAP.
General Prophylactic Measures
Most episodes of pneumonia are attributed to aspiration of Maintaining adequate staffing levels in the intensive care unit (ICU) can
oropharyngeal secretions into the distal airways and subsequent reduce length of stay, improve infection control practices and reduce
bacterial proliferation that results from impaired mechanical, the duration of mechanical ventilation.
2,3
Other effective infection
humoral or cellular defence mechanisms or as a result of an control measures that should be used routinely include staff education,
excessive bacterial load. Accordingly, attempts to prevent HAP have compliance with alcohol-based hand disinfection and isolation to
focused on reducing cross-transmission, the likelihood of aspiration reduce cross-infection with multidrug-resistant (MDR) pathogens.
4–7
and the bacterial load in the oropharynx. Micro-organisms can also
reach the lung by other routes, such as direct spread to the lungs The surveillance of ICU infections in order to identify and quantify
from the pleura or the mediastinum, haematogenous spread from endemic and new MDR pathogens is also recommended. In
distal foci (including the possibility of bacterial translocation from an addition, timely data for infection control and to guide appropriate
ischaemic gut in critically ill patients) and inoculation of aerosols. antimicrobial therapy in patients with suspected HAP or other
nosocomial infections should also be prepared.
4,6–9
An appropriate knowledge of the risk factors for the development of
HAP is crucial in implementing effective preventative measures. Intubation and Mechanical Ventilation
These risk factors can be either modifiable or non-modifiable. Intubation and mechanical ventilation are associated with an
The modifiable risk factors for HAP have been proposed in the increased risk of HAP and therefore should be avoided whenever
classification of the recommendations in recent guidelines,
1
as follows: possible.
4,6,10
Non-invasive positive-pressure ventilation (NPPV) is an
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