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Prevention and Treatment of Hospital-acquired Pneumonia
Ageing facilitates the deterioration of colonisation immunity.
84
Once Table 1: Risk Factors for Infection by
colonisation immunity has been compromised, the specific Gram-
Multiresistant Micro-organisms
negative bacilli colonising the oropharynx depends primarily on prior
exposure to antibiotics. Four patient scenarios can occur (see Figure 1):
Antibiotic treatment within the last 90 days for >5 days
Current hospital admission or within the last 90 days for >5 days
Immunosuppressive disease and/or treatment
• Healthy subjects are colonised with normal oropharyngeal flora in
Chronic dialysis within the last 30 days
whom pathogenic micro-organisms, such as S. pneumoniae, group
Epidemic outbreak in the unit by multiresistant organism
A streptococci or meningococci, may be found transiently.
• Patients with chronic co-morbidity or an acute inflammatory
Table 2: Initial Empirical Antibiotic Treatment in
process lose their colonisation immunity. As a result, S. aureus and Early-onset Hospital-acquired and Ventilation-assisted
enterobacteria can colonise the oropharynx (see Figure 2).
Pneumonia in Patients without Risk Factors for
Infection by Multiresistant Micro-organisms and with
• Patients who have received antibiotic treatment become colonised
Any Degree of Severity
with resistant microflora, including enterobacteria with extended-
spectrum β-lactamases (ESBL), Enterobacter, P. aeruginosa or
Probable Micro-organism Recommended Empirical Antibiotic
MRSA (see Figure 3).
Streptococcus pneumoniae Ceftriaxone; or
• Patients who receive broad-spectrum antibiotic schedules for more
Haemophilus influenzae Levofloxacin; or
than seven days are colonised by multiresistant micro-organisms Methicillin-resistant Ertapenem
(see Table 1). Intubation is an aggravating factor. This leads to the Staphylococcus aureus
emergence of the more resistant non-fermenting Gram-negative
Enteric Gram-negative bacilli
bacilli (A. baumanii, S. maltophilia, B. cepacia) and Gram-positive
Escherichia coli
micro-organisms (coagulase-negative Staphylococcus and
Klebsiella pneumoniae
Enterococcus spp.) (see Figure 3).
Enterobacter spp.
Proteus spp.
Changes in oropharyngeal flora tend to occur progressively so that the
Table 3: Initial Empirical Antibiotic Treatment for
micro-organisms present at one stage can overlap with the next stage
Late-onset Hospital-acquired and Ventilation-assisted
(see Figure 1).
Pneumonia in Patients with Risk Factors for
Infection by Multiresistant Micro-organisms and with
Empirical Antibiotic Treatment in
Any Degree of Severity
Ventillator-acquired Pneumonia
Patients with VAP may be classified into two groups with respect to
Probable Micro-organism Combined Antibiotic Treatment
Micro-organisms from Table 2 plus: Antipseudomonic cephalosporin
empirical selection: those with no prior antibiotic therapy and those
(ceftazidime or cefepime); or
with prior treatment. Patients who have not undergone antibiotic
Pseudomonas aeruginosa Carbapenem
treatment within the previous month may be treated with
(imipenem, meropenem); or
monotherapy (see Figure 1 and Table 2) using a β-lactam without
Klebsiella pneumoniae (ESBL+) Betalactamic/β-lactamase inhibitor
antipseudomonal activity, e.g. third-generation cephalosporin (such as
(piperacillin/tazobactam); +
ceftriaxone or cefotaxime), ertapenem, amoxicillin–clavulanate or a Serratia marcescens Antipseudomonic fluoroquinolone
fluoroquinolone, e.g. levofloxacin or moxifloxacin (see Figure 2). (ciprofloxacin, levofloxacin); or
Fluoroquinolones should not be administered in monotherapy in ICUs
Acinetobacter spp. Aminoglycoside (amikacin); ±
in which enterobacteria have a high rate of quinolone resistance.
Methicillin-resistant linezolid or vancomycin
Staphylococcus aureus
Patients who develop VAP after receiving antibiotic treatment or
Legionella pneumophila
Other non-fermentative GNB
following seven to 10 days in the ICU may be infected by resistant
Gram-negative bacilli (see Figure 3 and Table 3). An antipseudomonal
Linezolid or vancomycin are indicated in case of suspicion of Methicillin-resistant
Staphylococcus aureus. ESBL = extended-spectrum β-lactamase; GNB = Gram-negative bacilli.
antibiotic is indicated if the infection is severe or the patient fulfils the
risk factors for colonisation by multiresistant micro-organisms cavitation or the presence of Gram-positive cocci in sputum, empirical
(antibiotic treatment or intubation for more than seven to 10 days). linezolid or vancomycin may be appropriate. Tigecycline may be an
Priority should be given to treatment with a β-lactam. The choice of the option, although there has been little clinical experience with this.
β-lactam should take the following into account: in vitro susceptibility
of P. aeruginosa in the ICU, the prevalence of ESBL-producing Legionella spp.
enterobacteria, the result of prior cultures and prior antibiotics Infections by Legionella pneumophila serogroup 1 can be diagnosed
administered to the patient. An antipseudomonal β-lactam would by a Legionella urinary antigen test. This test should be obtained
include a third-generation cephalosporin (ceftazidime or cefepime), routinely if the hospital water supply is known to be colonised with
piperacillin–tazobactam or a carbapenem (imipenem or meropenem). L. pneumophila serogroup 1. A fluoroquinolone would be appropriate.
Special Situations Adjustment of Therapy
Methicillin-resistant Staphylococcus aureus After 72 hours, treatment should be adjusted based on the
The decision to add an anti-MRSA antibiotic depends on the microbiologic results:
prevalence of MRSA in the ICU and the severity of infection. In
geographical areas with a documented presence of community- • The initial β-lactam should be maintained if the micro-organism is
acquired MRSA, severe pneumonia with radiological images of susceptible to the empirical β-lactam prescribed originally; if the
EUROPEAN RESPIRATORY DISEASE 63
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