Refers to pneumonia occurring ≥ 48h after admission to hospital, excluding those from LTC or other health care settings (e.g. dialysis)
A diagnosis of pneumonia generally requires a demonstration of an infiltrate of chest imaging; X-rays may be negative in immunocompromised hosts or severely dehydrated patients
Fever, dyspnea, cough and sputum production comprise clinically compatible symptoms
Blood and sputum cultures should be obtained in; noninvasive sampling is preferred
Procalcitonin of > 0.5 mcg/L (>0.25 mcg/L in ICU patients) has a high positive predictive value for bacterial pneumonia. Antibiotics are discouraged when PCT is negative (<0.25mcg/L)
Legionella urine antigen can be ordered on inpatients if interstitial/atypical X-ray findings or risk factors (hot tub exposure, travel)
Serology (IgM) for mycoplasma is no longer indicated
The Respiratory Pathogen Panel (RPP) tests for 22 different respiratory pathogens by PCR, including atypical organisms and viruses, and can be ordered in patients in the ICU or upon approval from Medical Microbiology
In patients with cavitary pneumonia consider TB, fungal pathogens and Nocardia
In immunocompromised patients consider opportunistic pathogens such as PJP, CMV and fungal pathogens
Guidelines no longer recommend prolonged treatment
Therapy may be extended based on slow clinical improvement, or radiological and laboratory parameters
Pseudomonas, Acinetobacter, Stenotrophomonas and Staph aureus HAP/VAP may require longer duration of treatment
Procalcitonin is useful in determining duration; normalization warrants stopping treatment, a 50% reduction indicates improvement and step-down may be considered
OR, IF Immunocompromised or known ESBL/AmpC
IF AT RISK FOR MRSA ADD
Known colonization
Necrotizing pneumonia
Recent influenza
Injection drug use
Broad spectrum antibiotic use in last 90 days
Known colonization
COPD with FEV1 < 50%
Severe structural lung disease
Recent broad-spectrum antibiotics
Recent hospitalization
Stop vancomycin if MRSA absent from culture/screening swabs
If no pseudomonas isolated, can narrow coverage or use non-anti-pseudomonal doses
Cultures are helpful in guiding therapy, especially if organisms are present on the gram stain
Refrain from treating candida in the sputum unless suspecting systemic candidiasis (e.g. neutropenic, transplant patients)
Cultures may continue to be positive despite treatment in ventilated patients; refrain from re-culturing if patient improving
Usual pathogens
Early HAP/VAP (< 5 days of hospitalization)