1. Healthcare Associated Pneumonia

2. Case  70 year/male independent ADL non smoker, negative for ethanol intake  Presented with LOC to ED  On examination at home pt was confused and in Afib.  Amiodarone and digoxin were given  4 day history of malaise, loss of appetite,fever and diarrhoea  Palpitations, diplopia and gait disturbances in last 2-3 days

3. Additional historical points??  DM on OHAs and amlodipine for HTN  Known chronic bronchitis with last reported exacerbation dating 2 months back  On inhaled steroids, LABA, aspirin and metformin  Known case of carotid stenosis

4. Baseline exams  O2 sats 84%,NYHA grade IV, Tachycardia (130/min),Hypothermic, Tachypnoiec with a borderline BP  Confused, diplopia, poor response to verbal stimuli  Crackles and reduced air entry at right lung base  Cardiac and abdominal exams non contributory

5. Differentials????  ?Neurological  ?Arrythmia  Infection  Thromboembolic phenomena  Hypovolemia  ????????

6. More thoughts?????  Septic shock ??? CAP related + significant contribution of Afib  Microbiology work up including cultures (blood/sputum),serology and urinary antigens, Diagnostic tap  ICU admission  Fluid resuscitation + pressors  Venturi/NIV  Abx- Ceftriaxone,ertapenem,Macrolide + Vancomycin

7. Going further…….  Progression of MODS including ARF, deranged hepatic enzymes and increased FiO2 requirements on NIV  On amiodarone for A fib  USG abd noncontributory  Blood culture for klebsiella is positive

8. What further????

9. Original HCAP Definition?

10. Epidemiology????

11. Any change in strategy????

12. Choice of Abx Therapy????  Continue the same???  Remove Vancomycin????  Change from Ceftriaxone????  What about Macrolide???  What about a fluroquinolone??

13. Going further???  Initiated on carbapenem + single dose aminoglycoside  Blood cultures- Klebsiella  Catheter culture- Coagulase negative staph (probable colonizer)  Rest cultures-negative

14. Other things to be kept in mind????

15. Some more scores

16. Confounders????

17. PES: To suspect MDRM in CAP

18. Going back to the patient????  Patient improved clinically and his MODS resolved  Platelet counts, Creatinine levels and FiO2 requirements stabilized and decreased  CT Chest was planned

19. Further Imaging

20. Confounders???  Right pleural effusion with atelectasis of right lower lobe  Heterogenous hepatic lesions consistent with ???Mets/???Abscess  CT Brain was consistent with a multi infarct state

21. Going further????  A sono guided aspiration is done and pus is noted in the sample  The pus is sent for culture and grows klebsiella with a similar sensitivity report  A colonoscopic study was planned and done (S.Bovis)  A surgical procedure was ruled out in consultation with surgeon  Carbapenem (meropenem) was continued for two weeks followed by ertapenem for two weeks

22. To Conclude………  HCAPs have become very common in today,s scenario  Klebsiella remains a dominant organism in most of Indian ICUS  Deescalation from meropenem/imipenem to ertapenem should be considered  Use of ertapenem in CAP as an empirical choice is a viable option  It remains a hitherto less recognized entity  Absolutely no Indian data