When your patient has pneumoniaWhether acquired in the community or in the hospital, this potentially fatal infection could land a

patient in your ICU. Follow these guidelines to treat his condition.

By Susan Simmons Hoicomb, RN, ARNP,BQ MN, PhD

A ll too common and potentially deadly, pneumoniacan be acquired either in the community or in thehospital. Typical causative pathogens differ for

each type, as do treatments and outcomes. In this article,I'll compare bospital-acquired pneumonia with community-acquired pneumonia, either of which could send a patientto the intensive care unit (ICU). I'll also discuss whatyou can do to protect your vulnerable patients frompneumonia.

HAP, VAP, and CAP

Hos\nta\-acquUed pncumoma (HAP), also known as noso-comial pneumonia, is the leading cause of death fromhospital-acquired infections,with a mortality rate ofabout 50%. Up to 25% ofICU patients develop HAF^

By definition, HAP ispneumonia that occurs 48or more hours after hospitaladmission. When HAPdevelops in a mechanicallyventilated patient 48 to 72hours after endotrachcal(FT) intubation, it's called\enli\ato\-associated pneumo-nia (VAP).

Aspiration of pathogensfrom the oropharyngeal tract(typically Gram-negative bacilli and Gram-positive cocci)cause VAP and most other cases of HAP The lungs of about75% of severely ill patients are colonized via aspirationwithin 48 hours of hospital admission.'

Communily-acmmed pneumonia (CAP) most commonlyresults frotn infection with Streptococcus pneumoniae, but italso can be caused by Haanophilus injluenzae or MoraxeWacatarihalis.^ Atypical pathogens associated with CAPinclude legionella, influenza A and B, avian influenza, andcommunity-acquired methicillin-resistant Slaphylococcus

aureus (CA-MRSA).̂ About 20% of patients who developCAP need to he hospitalized.^

Who's at risk?Patients are at increased risk for either type of pneumoniaif they smoke, have compromised immune function, havea chronic lung disease, haven't received a pneumococcalvaccination, have had antibiotic therapy within the past 90days, or are very old or very young.

For HAP, additional risk factors include being hospital-ized 5 or more days, being transferred from one health carefacility to another, undergoing mechanical ventilation, hav-ing a decreased level of consciousness, aspirating food or

fluid, undergoing chestsurgery, receiving stressulcer prevention therapythat increases gastric pH,having a nasogastric tube,and being hospitalized inthe fall or winter.^

Recognizing pneumonia

Signs and symptoms ofpneumonia include fever,cough, purulent sputum,and leukocytosis (whichcan be associated with aleft shift or increase in im-mature neutrophils). When

leukopenia occurs, its associated with a poorer outcome.^

Diagnostic tests include a chest X-ray, complete bloodcell count, electrolytes, glucose level, renal and liver func-tion tests, and oxygen saturation. Two hlood cultures and asputum stain and culture and sensitivity should be obtainedbefore treatment begins.

The chest X-ray may not show pulmonary infiltratesuntil 1 to 2 days after initial signs and symptoms, or longerif the patient is dehydrated or intubated. However, it's stilluseful for monitoring changes.' *^

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CRITICALCdi

What else can go wrong?

Complications of pneumonia include meningitis, arthri-tis, endocarditis, pericarditis, peritonitis, empyema, andsecondary HAP. Complications such as sepsis, acute res-piratory distress syndrome, and multisystem organ fail-ure are more common in HAP and VAP than in ^

In iniubated patients, the clinical pulmonary infectionscore (CPIS) can help accurately diagnose pneumonia. TheCPIS is derived from the patient's temperature, whiteblood cell count. Lracheal secretions, oxygenaiion, andchest X-ray trends.

How sick is your patient?The pneumonia severity index (also known as the PORTcriteria, named for the Pneumonia Patient Outcomes Re-search Team that developed it) is used in conjunctionwith clinical judgment to determine whether a patientwith CAP should be hospitalized. '̂"^ Patients who fallinto classes IV and V, the top two classes on the PORTsystem, are at higher risk for death because of age, co-morbid conditions, and clinical condition, and should bebospitalized.^"^

Admission criteria for the ICU are based on the pneumo-nia severity index and the provider's clinical judgment. Apatient should be admitted to the ICU if he has one majorcriterion (mechanical ventilation or septic shock with theneed for vasopressors) or two minor criteria (systolic BPless than 90 mm Hg, multilobar infikrates, or a Pao/FjO^ratio of 250 or less).^

For information on potential complications of pneumo-nia, see What else can go wrong?

Treating CAPYour lacility's iniectious disease committee should reviewappropriate antibiotic therapy for CAP and HAP annu-ally because antibiotic resistance and other factors suchas pathogen profile differ among communities and hospi-tals. The follovving are general treatment recommenda-tions.

PatienLs with CAP severe enough to require ICU admis-sion are treated with intravenous (I.V.) antibiotics—a beta-lactam and either a macrolide or a fluoroquinolone, ifthere's no risk that the patients infection is from Pseudo-monas aeruginosa?

Risk factors for infection with P. aemginof>ii includestructural lung disease, chronic steroid therapy of greaterthan 10 mg of prednisone daily, use of a broad-spectrumantibiotic for more than 7 days in the previous month, or

Which drug for which bug?

These are the generally recommended antibiotics fortreating HAP or VAP caused by the following organisms.

Causative agent Antibiotic

P. aeruginosa imipenem or meropenem. Ifresistance to these two antibi-otics is a concern, alternativesinclude piperacillin, ceftazi-dime, cefepime, aminoglyco-sides, or fluoroquinolones.Some strains are susceptibleonly to polymyxin B.

Klebsiella, Enterobacter, carbapenemsand Serratia

Acinetobacter carbapenems or sulbactam

Methidllin-resistantStaphylococcus aureus

vancomycin. In some areaswhere vancomycin resistanceis high, linezolid resistance israre, so linezolid is the anti-biotic of choice.

malnutrition. If your patient has one of these risk factors,administer one of the following I.V antibiotic regimens asordered:

• an antipseudomonal beta-lactam agent (cefepime,imipenem, meropenem, or piperacillin/tazobactam), pluseither ciprofloxacin or levofloxacin• an antipseudomonal beta-lactam agent plus an amino-glycoside and azithromycin• an antipseudomonal beta-lactam and a fluoroquinolone.Patients allergic to penicillin should be given aztreonaminstead of the beta-lactam.

Duration of therapy usually is 7 to 14 days, although atreatment duration as short as 5 days may be acceptable.The patient may receive 3 days of I.V. therapy and then beswitched to oral antibiotics if tolerated and if he meets thefollowing criteria: afcbrile on two separate occasions at least8 hours apart, improvement in cough and shortness ofbreath, a normalizing white blood cell count, and a func-tioning gastrointestinal tract.^ At this point, he may be ableto move out of the ICU unless he has other conditionsrequiring a longer ICU stay.

Treating HAP and VAPCurrent guidehnes for treating HAP and VAP take into ac-count that antibiotic resistance is an ongoing problem that

48cc2 I Nursing2007 i June www.nursing2007.com

may vary depending on geographic region. For generalrecommendations, see Wliitfi dm^^jor which hug?

Clinical response to antibiotic treatment should beapparent within 72 hours.^ If the patient's clinical conditionworsens or fails to improve within 3 days, the prescribershould consider changing the antibiotic regimen. If thepatients condition improves, he can be switched to oralantibiotics after 3 days as described above.

Preventing pneumoniaMeticulous hand hygiene can help reduce the incidence ofall types of infection, including pneumonia. Here are someother steps you or your patient can take to prevent pneu-monia.

To prevent CAP, advise patients at risk to keep theirpneumococcal vaccination up-to-date. These patientsinclude those with chronic obstructive pulmonar>' disease,anyone over age 65, and anyone who's had a splenectomy.Also advise patients to get a yearly influenza vaccinationaccording to Centers for Disease Control and Preventionguidelines. Other strategies to reduce infection risk includegetting adequate rest and good nutrition, not smoking, andcovering the mouth and nose when sneezing or coughing.(If a sink or hand sanitizer aren't readily available, cough orsneeze into your elbow or upper arm instead of your hand,to reduce germ transfer.)

Preventive measures for HAP and VAP are aimed atreducing the patient's risk of aspiration and preventing bac-terial colonisation in the oropharnyx, stomach, and sinuses.• Reduce aspimlion lish by not placing the patient supine.Unless contraindicated, raise the head of the bed 30 to 45degrees. To keep his stomach from becoming overdis-tended, reduce opioid and anticholinergic use when possi-ble, and administer gastrointestinal motility-enhancingagents if prescribed. If he's receiving enteral feedings, usesmall-lumen feeding tubes and instill feedings in the smallbowel instead of the stomach, if possible.^ Monitor resid-ual volumes in patients receiving intragastric tube feedingsand follow your facility's policies and procedures for hold-ing feedings if indicated.

' Avoid endotracheal intubation whenever possible. Ad-minister positive-pressure ventilation noninvasively viamask. If the patient must be intubated, keep intubationtime as short as possible, and try to use the ora! routeinstead of the nasal route. (Researchers are working todevelop endotracheal tubes that resist biofilm, a bacterialcoating that forms on tubes and can spread pathogens tothe patient's lungs.) Keep ventilator tubing drained andchanged per facility pohcy and avoid unnecessary venti-lator circuitry manipulation. Perform frequent oral care

and suctioning, using an ET tube with continuous aspi-ration of subgiottic secretions if it's available. Follow theInstitute for Healthcare Improvement's recommended in-terventions for reducing VAP, including daily interrup-tion of sedation."

• Help the patimt peifomi aggressive pulmonaty toilet as tol-erated.

• Minimise the number of patient transporls^-'*-^° Being in-lubated and recumbent increases aspiration risk.

• Use sucraljate if the patient needs stress ulcer prophylaxis.Sucralfate, which can be used in mechanically ventilatedpatients or any patient not being fed via the stomach, isassociated with a lower risk of pneumonia. Using hista-mine blockers, antacids, or other agents that increasestomach pH is associated with a higher incidence of pneu-monia.^

• Perfoivi meticulous oral care. Using chlorhexidine pastein the mouth reduced VAP rates 65% in one study, al-though other studies have had mixed results, especially re-lated to bacterial resistance.^

Staying on top of thingsBy understanding pneumonia in the critical care setting,you can help patients avoid this potentially fatalinfection. O

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2. BartleliJG. Diagnostic approach to LOinnuiniiy-aiquired pneumoniain adults. t'pToDntf. 2006, http://www.nl do I. eo7ut«l/conteiit/lopk.do7Key=pulmJnf/8745&typc+A&sclcctedTitle=l-45. Accessed December8, 200f..

.3. ATS guidelines: Community-dcquircd pneiimi>ni.i in adult.s. I'pToDatc.2006. http-J/yvwY/.uidol.com/iitd/conteni/topic.do?tapicKey=ats_gtud/31388&typc=A&selectedTiUe=4-62 Accessed December 8, 2006.

4. Woods A, Hathaway L. Treating community-acquired pneumonia. ThtNurse Practitioner. 29(6):11-13, June 2004,

5. Mandell LA, et al. Update of practice guidelines for the managementof community-acquired pneumonia in immunocompetent aclulis Na-tional Gtticleline ciearinghouse, 200.3. hitp://www.gaiddines.gov/saininary.aspx?docJdi:4546&nbr=003360+siring=mafidell+AND't-laAccessed April 10, 2007.

6. KoUef MH. Prevention of hospital-associated pneumonia and ventilaior-associated pneumonia. Critical Care MciJicitic. 32{6):1.3yfi-1405 )une2004.

7. Pnjiii B, Jacobs M. Best-practice interventions: How can you preventventilator-associated pneumonia? Nursing2006. 36(2):36-42 February2006.

8. Koeman M, et al Oral decontamination with chlorhexidine reducesthe incidence of ventilator-associated pneumonia, Amaican Joumal ofRespircilary and Critical Cart- Medicine. 173(12):1348-1355. June 15,2006.

Susan Simmons Holcomb is a nurse practitioner at Olathe (Kan.) MedicalSen/ices, Inc., and a consultant in continuing nursing education at Kansas City(Kan.) Community College.

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