Ten Issues to Update in Nosocomial or Hospital-Acquired Pneumonia: An Expert Review

Abstract

Nosocomial pneumonia, or hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP) are important health problems worldwide, with both being associated with substantial morbidity and mortality. HAP is currently the main cause of death from nosocomial infection in critically ill patients. Although guidelines for the approach to this infection model are widely implemented in international health systems and clinical teams, information continually emerges that generates debate or requires updating in its management. This scientific manuscript, written by a multidisciplinary team of specialists, reviews the most important issues in the approach to this important infectious respiratory syndrome, and it updates various topics, such as a renewed etiological perspective for updating the use of new molecular platforms or imaging techniques, including the microbiological diagnostic stewardship in different clinical settings and using appropriate rapid techniques on invasive respiratory specimens. It also reviews both Intensive Care Unit admission criteria and those of clinical stability to discharge, as well as those of therapeutic failure and rescue treatment options. An update on antibiotic therapy in the context of bacterial multiresistance, in aerosol inhaled treatment options, oxygen therapy, or ventilatory support, is presented. It also analyzes the out-of-hospital management of nosocomial pneumonia requiring complete antibiotic therapy externally on an outpatient basis, as well as the main factors for readmission and an approach to management in the emergency department. Finally, the main strategies for prevention and prophylactic measures, many of them still controversial, on fragile and vulnerable hosts are reviewed.

Keywords: diagnosis stewardship; epidemiology; etiology; healthcare-associated pneumonia; hospital at home; management; nosocomial pneumonia; prevention; radiologic findings; readmission; rescue; therapeutic failure; vaccination.

Figure 1

Modified PANNUCI algorithm from empirical to targeted treatment on nosocomial pneumonia in ICUs in European countries (both immunocompetent and immunosuppressed). AT: antimicrobial therapy; vHAP: ventilated hospital-acquired pneumonia; VAP: ventilator-associated pneumonia; MDR: multidrug resistant; PCR: polimerasa chain reaction; CFT/TAZ: ceftolozan/tazobactam; CAZ/AVI: ceftazidime/avibactam; PIP/TAZ: piperacillin/tazobactam; AMG: aminoglycoside; AZT: Aztreonam; EAT: empirical antimicrobial treatment; TAT: targeted treatment; OXA-48: OXA-48 Carbapenemase; KPC: Klebsiella pneumonie Carbapenemase; MER-VAR: MEROPENEM-VABORBACTAM; IMI-REL: IMIPENEM-RELEBACTAM; ESBL-E: extended spectrum beta-lactamase-producing enterobacteria; PJ: Pneumocystis jiroveccii. * If Oxa-48 susceptible to CAZ/AVI.