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​Overview​​​

Pneumonia, an acute illness, is defined by the Centers for Disease Control and Prevention (2014) as: “an infection of the lungs that can cause mild to severe illness in people of all ages.” Pneumonia can be caused by viruses, bacteria, and fungi (Centers for Disease Control, 2015). By consensus, pneumonia that develops at least 48 hours after hospital admission, (excluding those which were incubating at the time of admission) is considered to be hospital-acquired pneumonia (HAP).

The most common pathogens are gram-negative bacilli and Staphylococcus aureus; drug-resistant organisms are an important concern. Symptoms and signs are the same as those for community-acquired pneumonia. Diagnosis is suspected on the basis of sepsis criteria together with chest x-ray changes and cough (productive with bacterial pneumonia). Nasopharyngeal swabs for viral testing can confirm the diagnosis in cases of influenza and other respiratory viruses. Sputum cultures for bacteria should be obtained but have poor sensitivity and specificity. Cultures obtained by bronchoalveolar lavage may have better specificity but lower sensitivity. They do not alter outcomes and therefore it is recommended to not perform this procedure routinely (Muscedere, Dodek, et al, 2008). Blood cultures should be obtained but have very low sensitivity. Treatment is with antibiotics. Overall prognosis is poor, due in part to comorbidities.

HAP, ventilator-associated pneumonia (VAP), and healthcare-associated pneumonia (HCAP) remain important causes of morbidity and mortality despite advances in antimicrobial therapy, better supportive care modalities, and the use of a wide-range of preventive measures. HAP may be managed in a hospital ward or in the intensive care unit (ICU) when the illness is more severe. VAP refers to pneumonia that arises more than 48 hours after endotracheal intubation. Although not included in this definition, some patients may require intubation after developing severe HAP and should be managed similar to patients with VAP. HCAP includes any non-hospitalized patient with pneumonia who was hospitalized in an acute care hospital for two or more days within the past 90 days; resided in a nursing home or long-term care facility; received recent intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days; or attended a hospital or hemodialysis clinic within the past 30 days of the infection.

Although this document focuses more on HAP and VAP, most of the principles overlap with HCAP. Because most of the current data have been collected from patients with VAP, and microbiologic data from non-intubated patients may be less accurate, most of our information is derived from those with VAP, but by extrapolation can be applied to all patients with HAP, emphasizing risk factors for infection with specific pathogens (American Thoracic Society and Infectious Diseases Society of America, 2005).

Based on 2002 data, nearly 80 per cent of all hospital-acquired infections are caused by four types of infections. Urinary tract infections (UTIs) comprise the highest percentage (34 per cent of all hospital-acquired infections), followed by surgical-site infections (17 per cent), bloodstream infections (14 per cent), and pneumonia (13 per cent) (Klevens et al., 2007).

“In non-intubated patients, risk factors include previous antibiotic treatment, high gastric pH (due to stress ulcer prophylaxis or therapy), and coexisting cardiac, pulmonary, hepatic, or renal insufficiency. Major risk factors for postoperative pneumonia are age > 70, abdominal or thoracic surgery, and dependent functional status,” (Sethi, 2014).

Implications

According to the Centers for Disease Control and Prevention (Centers for Disease Control, 2014), hospital-associated pneumonia “has accounted for approximately 15 per cent of all hospital-associated infections.” (Tablan et al., 2003) Hospital-acquired pneumonia, and notably ventilator-associated pneumonia, developing as a consequence of lung bacterial colonization, alters clinically important outcomes, including duration of mechanical ventilation, length of stay in the intensive care unit (ICU), and mortality rates (Roquilly et al., 2015).

For the Canadian healthcare system, the incidence of VAP is 10.6 cases per 1000 ventilator days. Using conservative assumptions, we determined that VAP costs approximately $11,500 per case, is responsible for approximately 230 deaths per year (5.8 per cent), and accounts for approximately 17,000 additional ICU days per year -- around two per cent of all ICU days in Canada. This represents the equivalent of three to four ICUs completely occupied for the whole year solely to treat patients with VAP. Finally, the cost to the healthcare system is [estimated to be] CAN $46 million per year (Muscedere, Martin, et al, 2008).

Non-ventilator hospital-acquired pneumonia (NV-HAP) is an underreported and understudied disease, with potential for measurable outcomes, fiscal savings, and improvement in quality of life (Quinn et al., 2014). Many Canadian hospitals monitor ventilator-associated pneumonia; however, there is only limited monitoring and reporting of NV-HAP.

The limited studies available indicate that NV-HAP is an emerging factor in prolonged hospital stays and significant patient morbidity and mortality.

HAP​​:​​

a.   Adds an estimated additional $40,000 to $65,000 to the cost of care for each affected patient in the U.S.

b.   Adds seven to nine days to the length of hospital stay.

c.   Significantly increases discharge to skilled nursing facilities instead of returning home.

d.   Has an attributable mortality rate as high as 50 per cent.

e.   Is associated with half of patients not being discharged back to their homes.
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While HAP has received significant attention from healthcare quality review boards, their focus has been on intensive care unit (ICU)-level of care and ventilated patients who acquire pneumonia (Quinn et al., 2014).

Several factors may contribute to increased risks for HAP, including older patients with a low body mass index and signs of malnourishment; altered mental status; low albumin; dependent for activities of daily living; receiving central nervous system depressants or acid blocking medications; and presence of chronic or inadequately managed pain (Quinn et al., 2014).

Modifiable risk factors for HAP and VAP are crucial targets for prevention that can reduce patient mortality and morbidity, and also promote the cost-effective use of healthcare resources. Effective prevention strategies include the use of strict infection control, hand hygiene, microbiological surveillance with availability of data on local drug resistant pathogens, monitoring and early removal of invasive devices, and programs to reduce or alter antibiotic prescribing practices (Rotstein, 2008).

Goal

To prevent hospital-associated pneumonia in hospitalized adult patients by implementing proven interventions.