Hospitals pneumonia (GAP) developed at least 48 hours after hospitalization. The most common pathogens are gram-negative rods and
; drug-resistant microorganisms is an important issue. Symptoms and signs are the same as those acquired pneumonia, but in ventilated patients, pneumonia may manifest as worsening oxygenation and increased tracheal secretions. Diagnosis is suspected based on clinical and chest X-ray and confirmed by culture of blood or bronchoscopy sample of lower respiratory tract. Treatment with antibiotics. Overall prognosis is poor, partly because of comorbidities. HAP includes ventilator-associated pneumonia (VAP), postoperative pneumonia and pneumonia that develops in neprovitryuvanyh, but otherwise moderate or critically ill hospitalized patients stationary. It also includes a new category of healthcare-associated pneumonia (HCAP), which refers to pneumonia acquired by patients in medical institutions, such as chronic health care facilities, dialysis centers, and infusion centers. The most common cause is mikroaspiratsiya bacteria that colonize the oropharynx and upper respiratory tract of seriously ill. 85% of all cases of pneumonia occurring in 17 to 23% of ventilated patients. Endotracheal intubation violation respiratory protection, reduces cough and mucociliary clearance and promotes mikroaspiratsiya bacteria laden secret that pool above inflated endotracheal tube cuff. In addition, the bacteria form a biofilm and within the endotracheal tube, which protects them from antibiotics and host defenses. In nonintubated patients, risk factors include prior antibiotic treatment, the high pH of the stomach (due to stress ulcer prophylaxis or therapy), and coexisting cardiac, pulmonary, hepatic or renal insufficiency. Major risk factors for postoperative pneumonia
age 70, abdominal or thoracic surgery, and depends on the functional state. Pathogens and antibiotic resistance patterns vary considerably between institutionsand can vary within institutions for short periods (eg month to month). Overall, the most important pathogen, which is especially common in pneumonia acquired in intensive care and in patients with cystic fibrosis, neutropenia, advanced AIDS, and bronchitis. Other important pathogens include Gram-negative enteric bacteria (mostly
SP,,,,
SP, and. Staphylococcus aureus, and
often implicated when pneumonia develops within 4 to 7 days hospitalization, while the enteric gram-negative bacteria are becoming more common with increasing duration of intubation. Patients with HAP through
Staphylococcus aureus or gram-negative bacteria, usually elderly or serious circumstances, such as requiring ventilator that undergoing chemotherapy for cancer, or have chronic lung disease. to antibiotics increases the likelihood of polymicrobial infection, resistant bacteria, including methicillin-resistant Staphylococcus aureus
and
infection. Infection resistant organism significantly affects mortality and morbidity. infection. Symptoms and signs in nonintubated patients, usually the same as that for pneumonia (qv). Pneumonia in the critically ill, mechanically ventilated patients more typically causes fever and increased respiratory rate or heart rate or changes in respiratory parameters such as increased purulent secretions or worsening hypoxemia. diagnosis is imperfect. In practice, HAP is often suspected on the basis of new infiltrate on chest x-rays taken to assess new symptoms or signs, or leukocytosis. However, no symptom, sign, or X-ray output sensitive or specific to diagnose because it may be due to atelectasis, pulmonary embolism, or pulmonary edema and may be part of the clinical. results in acute respiratory distress syndrome, alternative diagnoses should be sought, particularly in patients with pneumonia risk score 6 (see . Table 5:
). Gram and culture of endotracheal aspirate with uncertain benefits, as designs are likely to be contaminated with bacteria that are colonizers and pathogens, and a positive culture may or may not indicate infection. bronchoscopy sampling lower airway secretions for quantitative culture seems to give more reliable models, but the effect on the results of this approach is not defined. Measurement of inflammatory mediators in bronchoalveolar lavage fluid may play a role in future diagnosis, for example, the concentration of soluble receptor startup expressed on myeloid cells (proteins expressed by immune cells shed during infection)
5 pg / ml to help distinguish between bacterial and fungal pneumonia uncommunicable causes clinical and radiographic changes in ventilated patients. However, this approach requires further study. only conclude that reliably identifies as pneumonia and responsible body pleural fluid culture is positive for respiratory pathogen. blood cultures if relatively specific respiratory pathogen identified, but not sensitive. mortality associated with HAP due to gram-negative infections ranges from 25 strattera to 50%, despite the availability of effective antibiotics . or death associated with underlying disease or pneumonia itself is uncertain. Women may be at greater risk of death.
mortality in Staphylococcus aureus pneumonia >> << ranges from 10 to 40%, partly because serious circumstances, with whom he associated. If the diagnosis is suspected, treatment with antibiotics, which are chosen empirically based on local features of the sensitivity of specific patient risk factors and conditions listed in Table 2. Indiscriminate use of antibiotics is a major cause of resistance to antimicrobial agents such way of treatment. can start from the beginning of a wide range of products, which replaced most of the drug for certain pathogens identified culture. Alternative strategies to limit resistance, which were not effective, including antibiotics, stopping after 72 hours in patients with pulmonary infection score (Table 5.
6 and regularly rotating empirically selected antibiotics (eg, every 3 to 6 months) Several schemes exist, but all should include antibiotics that are effective against the resistant gram-negative and gram-positive microorganisms options. << include >> S.aureus. not be used for pulmonary infections. Most of the measures to prevent VAP. Semiupright or vertical positioning reduces the risk of aspiration pneumonia and compared with lying position and is the simplest and most effective preventive method. noninvasive ventilation using continuous positive airway pressure Navigation (CPAP) or two-level positive airway pressure (BiPAP) prevent infringement of respiratory protection that occurs when tracheal intubation and eliminates the need for intubation in some patients. continuously striving Subligamentous selection using a specially designed endotracheal tube attached to suction device may reduce the risk of aspiration., kolistyn, chlorhexidine,
cream, or combinations thereof) or the entire gastrointestinal tract (with polymyxin, aminoglycosides and fluoroquinolones, and either
) is controversial because of concerns about the resistance strains and that decontamination, although reduced rate of compensation has not been shown to reduce mortality. Observations culture and regularly changing schemes or Fan endotracheal tube has not been shown to reduce VAP. incentive spirometry is recommended to prevent postoperative pneumonia. last full review / revision May 2008, John Bartlett, MD.
