1. H CAP & H AP Pamela Charity, MD Cathryn Caton, MD, MS

2. O BJECTIVES Define pneumonia Define HAP and review the characteristics Define HCAP Diagnosing HCAP and HAP Treatment of HCAP and HAP Review treatment algorithm

3. K EY M ESSAGES Be familiar with the following: Definition of both terms Start antibiotics within 4 hours of making the diagnosis Know which antibiotics to start empirically Know where to access the antibiogram Know how and when to de-escalate antibiotic therapy

4. P NEUMONIA Fever Leukocytosis Infiltrate on CXR

5. H OSPITAL A CQUIRED P NEUMONIA Category of pneumonia that occurs 48 hours or more after admission Encompasses healthcare associated pneumonia and ventilator associated pneumonia

6. H OSPITAL A CQUIRED P NEUMONIA Time of onset Is an epidemiologic variable and Risk factor for specific pathogens and Affects outcomes

7. H OSPITAL A CQUIRED P NEUMONIA Early onset Within first 4 days Better prognosis More likely to be caused by antibiotic-sensitive bacteria Above is true unless patient Received prior antibiotics Have had prior hospitalization within 90 days Greater risk for colonization and infection with MDR pathogens

8. H OSPITAL A CQUIRED P NEUMONIA Late onset 5 days or more More likely to be caused by MDR pathogens risk factors for MDR Antimicrobial therapy in preceding 90 days Presence of risk factors for HCAP Immunosuppresive disease/therapy Increased morbidity and mortality

9. H EALTHCARE A SSOCIATED P NEUMONIA Category of pneumonia in patients with recent close contact with the health care system Hospitalized for 2 or more days within last 90 days Resides in nursing home or long-term care facility Received recent IV antibiotic therapy, chemotherapy, or wound care within past 30 days Hemodialysis

10. M AKING THE D IAGNOSIS History – this will determine the classification of pneumonia Physical exam findings Laboratory data Radiographic findings Antibiotics should be initiated within 4 hours of making the diagnosis.

11. C HOOSING E MPIRIC A NTIBIOTICS HCAP and HAP are treated similarly Think about multi-drug resistant pathogens Gram Neg Pseudomona Aeruginosa – some are only sensitive to polymyxin B Serratia Marcescens Klebsiella Enterobacter Acinetobacter Gram Positive MRSA VRE

14. C HOOSING E MPIRIC A NTIBIOTICS

15. D E - ESCALATION OF A NTIBIOTIC T HERAPY This may be appropriate if Clinical improvement at 48-72 hours Cultures are positive Treat for 7-8 days and reassess patient Single agent such as moxifloxacin may be appropriate May stop antibiotics if clinical improvement at 48-72 hours and cultures are negative

16. T REATMENT A LGORITHM

17. R EFERENCES ATS/IDSA Guidelines Am J Respir Crit Care Med Vol 171. pp 388-416, 2005