1. Goss, Linda K. ARNP, CIC, COHN-S, MSN

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HOSPITAL-ACQUIRED PNEUMONIA (HAP) accounts for nearly 15% of all hospital-acquired infections. With a mortality of 20% to 33%, HAP is the deadliest of these infections.1,2 The American Thoracic Society (ATS) defines HAP as pneumonia that occurs more than 48 hours after hospital admission that wasn't present or incubating on admission.1 HAP includes ventilator-associated pneumonia, postoperative pneumonia, and pneumonia in nonventilated, critically ill patients.


In this article, I'll tell you about HAP, how it's treated, and how to implement prevention strategies. But first, let's look at who's at risk for HAP.


Vulnerable patients

Risk factors for HAP include these characteristics3,4:


* older than 70 years


* a smoker


* compromised immunity


* admitted to the hospital for burns, trauma, or a central nervous system disease


* previous thoracic or abdominal surgery


* malnutrition


* decreased level of consciousness


* underlying chronic lung disease


* conditions that may lead to gastric reflux.



Admission or transfer to the ICU increases the risk of HAP, mostly because the patient may require mechanical ventilation, another risk factor. Artificial airways or endotracheal tubes used in conjunction with mechanical ventilation allow oropharyngeal secretions to accumulate and the cough reflex to be suppressed.


When a patient develops pneumonia, his length of stay in the ICU can be prolonged up to 6 days and in the hospital up to 9 days with increased costs estimated at $40,000/patient.3


Sources of infection

HAP occurs when three conditions are present:


1. Host defenses are impaired.


2. Organisms reach the lower respiratory tract and overwhelm the host.


3. The organisms are highly virulent.



Some comorbid conditions predispose patients to HAP. Other risk factors include supine positioning, aspiration, coma, malnutrition, prolonged hospitalization, and metabolic disorders. Hospitalized patients can also be exposed to bacteria from other sources such as respiratory devices, equipment, and healthcare workers' hands. Intervention-related factors can also play a role. These include endotracheal intubation, thoracic or abdominal surgery, nasogastric tubes, and antibiotic therapy.5


Assessing for signs and symptoms

Knowing which patient is at risk and his baseline physical status will help you recognize changes. Signs and symptoms of pneumonia include cough, dyspnea, chest pain, fever, and overall weakness.


An older adult's cough may be dry due to mild or pronounced dehydration, but it's typically productive in younger adults. Dyspnea usually occurs with exertion and rarely while the patient is at rest. The patient may complain of chest discomfort and sometimes abdominal pain. Patients with HAP are likely to have a poor appetite, diaphoresis, and headache.


Expect a high temperature, usually greater than 100[degrees] F (37.8[degrees] C), and a heart rate of more than 100 beats/minute. However, if your patient is older, he may have pneumonia without a fever. Patients with underlying conditions such as chronic obstructive pulmonary disease may have a cough as their only symptom.


When you listen to your patient's lungs, you can generally hear rhonchi, or crackles, on both inspiration and expiration. To reach a diagnosis of pneumonia, the healthcare provider will take the patient's medical history, perform a physical exam, and order a chest X-ray and sometimes blood cultures. More invasive procedures such as bronchoscopy may be used to collect sputum for examination.


Intubated and more critically ill patients will show signs of pneumonia as indicated by their documented respiratory values, PaO2/FIO2, and other clinical signs and symptoms.


As a general rule, if your patient exhibits fever and cough, consider pneumonia. Older adults and young children may have nonspecific symptoms such as agitation, confusion, and restlessness.


Treatment for HAP or suspected HAP depends largely on the suspected causative organisms. (See Zeroing in on causative organisms.) Suspicion of HAP will most likely prompt a clinician to use the Clinical Pulmonary Infection Score (CPIS) to confirm the diagnosis.6 A CPIS is assigned based on certain clinical criteria such as fever and a decrease in blood oxygenation values. Once the patient is diagnosed with HAP, treatment will be based on the causative organism.

Table. Zeroing in on... - Click to enlarge in new windowTable. Zeroing in on causative organisms

Tailored treatment

The ATS and the Infectious Diseases Society of America updated their consensus statement for treatment of HAP in 2005.1 A panel of experts convened to develop a method of determining a consistent and evidence-based decision process for treating HAP.6 The guidelines include prevention and diagnosis criteria aimed at reducing HAP and improving outcomes.


The patient's treatment should be based on the healthcare facility's history of specific pathogens and susceptibility patterns (that is, what antibiotics are effective). Each patient population or facility has certain organisms that are most common. An antibiogram is a document about the prevalence of organisms and the antibiotics used to treat them. Serving as a facility-specific guide or sometimes a unit- or floor-specific guide, the antibiogram provides the clinician with a resource to help make treatment decisions specific to the patient population.


The antibiogram is also used as part of a risk assessment of a certain patient or type of patient.6 The risk assessment uses certain criteria including time from patient admission to acquisition of pneumonia, presence of mechanical ventilation, and whether the patient has been treated recently with antibiotics. Patients who have used antibiotics recently are more likely to have multidrug-resistant organisms and their treatment may be more difficult.


Other treatment guidelines include using antibiotics that are effective against a wider variety of organisms and changing the antibiotic only when the pathogen has been identified.7 Early on, a broad-spectrum antibiotic should be used, such as an antipseudomonal cephalosporin, carbapenem, penicillin, fluoroquinolone, or aminoglycosides. For organisms like Klebsiella pneumoniae or Acinetobacter species, carbapenems plus an aminoglycoside are used. Other classes of antibiotics include fluoroquinolones or macrolides. Monotherapy or combination therapy depends on the risk factors, whether an organism has been identified, and the mechanism of action of the antibiotics. Antibiotic-specific therapy is usually guided by collaboration among antimicrobial pharmacists, infectious disease physicians, and the microbiology department.


Inappropriate use of antibiotics including overuse can delay the overall response to therapy. The ATS and the Infectious Diseases Society of America updated their consensus statement on the consistent and evidence-based treatment of HAP in 2005. It states that antibiotic treatment duration should be as short as possible and no longer than 8 days.6


Hands-on nursing interventions

A patient who's at risk for pneumonia doesn't have to acquire it. The easiest intervention and one of the most underused is paying attention to hand hygiene and infection control practices.


An alteration in your patient's breath sounds may lead to a decreased tolerance for activity and a need for longer rest periods. An increased heart rate or tachycardia could lead to a decrease in oxygenation and a change in mental status. Using accessory muscles to breathe could lead to ineffective breathing patterns; positioning the patient correctly can help.


Anxiety related to hospitalization is common; in a patient with HAP, it could cause compromised respiratory function. Care for the oral cavity meticulously and strictly adhere to the oral care schedule to prevent microorganisms from being aspirated.8


Nutrition deficits related to feeding tube placement or poor appetite can lead to delayed healing. Assess the patient's feeding habits, including his likes and dislikes, and encourage him to eat. Care for enteral feeding tubes according to your facility's policies and procedures.9 Monitor the securement of the enteral feeding tube to prevent breakdown of the skin and also to reduce interruptions in feeding by accidental removal.


Routine maintenance and assessment of the patient's vascular access device can decrease his risk of phlebitis. Timely administration of antibiotics and other medications promotes improved outcomes, which can lead to a decreased length of stay. Using oxygen therapy when hypoxemia develops can cause patient discomfort; make sure he doesn't remove the cannula or mask.


Teaching patients

When encouraging your patient to cough and deep breathe, explain how this will help to clear his airway. If you're assisting with or performing oral care, explain that this will reduce the colonization of bacteria in his mouth. When you monitor his nutritional intake, explain that adequate nutrition promotes healing. When raising the head of the bed, explain that this helps to prevent aspiration of oral secretions into his lungs.


Explain why you're giving him a certain medication and tell him how often he'll receive it. When respiratory therapy is initiated, teach the patient that this will help him breathe and move secretions in his lungs.


Encourage family members to participate in the care of their loved one. Be prepared to provide resources or references for further education.


Steps for prevention

In 2004, the CDC published revised Guidelines for Preventing Healthcare-Associated Pneumonia.4 The guidelines were updated to include pneumonia that occurs in healthcare settings other than hospitals, organisms that cause HAP, and reinforcement of infection prevention and control practices. Because HAP has a high rate of morbidity and mortality, focus your efforts on prevention.


The following list details your role in prevention:


* Perform hand hygiene before and after patient contact.


* Elevate the head of the bed 30 to 45 degrees, if not medically contraindicated, to help prevent aspiration.


* Verify feeding tube placement regularly and check residual volumes to prevent distension that may result in aspiration.


* Perform oral care or assist the patient with it to reduce the organisms in his mouth.


* Encourage deep breathing and assist with ambulation, if not contraindicated, so the patient is better able to maintain a clear airway.


* Use the incentive spirometer as indicated for postoperative patients as a means of maximizing ventilatory volume and promoting cough to clear the airway.


* Ensure your patient receives his antibiotics as scheduled.


* Know and follow your facility's policy for replacing the suction equipment.



By recognizing the signs and symptoms of HAP in your patient and seeing that he gets appropriate treatment and teaching, you'll be playing your part in fighting this deadly disease. Finally, your steps to prevent HAP in vulnerable patients may be healthcare's most effective weapon against this common threat.




1. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416. [Context Link]


2. Centers for Disease Control and Prevention. Overview of pneumonia in healthcare settings. [Context Link]


3. Hospital-acquired pneumonia. Merck Manual Online Medical Library. [Context Link]


4. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R; CDC; Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care-associated pneumonia, 2003. MMWR Recomm Rep. 2004;53(RR-3):1-36. [Context Link]


5. Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner and Suddarth's Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2008. [Context Link]


6. Masterton R. The place of guidelines in hospital-acquired pneumonia. J Hosp Infect. 2007;66(2):116-122. [Context Link]


7. Craven DE. What is healthcare-associated pneumonia, and how should it be treated? Curr Opin Infect Dis. 2006;19(2):153-160. [Context Link]


8. Cason CL, Tyner T, Saunders S, Broome L; Centers for Disease Control and Prevention. Nurses' implementation of guidelines for ventilator-associated pneumonia from the Centers for Disease Control and Prevention. Am J Crit Care. 2007;16(1):28-36. [Context Link]


9. Pruitt B, Jacobs M. Best-practice interventions: how can you prevent ventilator-associated pneumonia? Nursing. 2006;36(2):36-41. [Context Link]



American Thoracic Society.


Association for Professionals in Infection Control and Epidemiology.