Lobar pneumonia - HAP

Question 1

What is the time frame for development of HAP?

Answer 1

Acute LRTI acquired after at least 48 hours of admission to hospital and is not incubating at the time of admission.

Question 2

How does HAP differ from VAP?

Answer 2

Distinct from VAP - acquired more than 48hrs post endotracheal intubation.

Question 3

What scoring system is used?

Answer 3

CPIS (Clinical Pulmonary Infection Score).

Question 4

What is the epidemiology of HAP?

Answer 4

· Extends hospital admission by 7-11 days.

· Common presentation in infection and in malignancy.

Question 5

Pathogens can reach the lower respiratory tract by which 4 mechanisms?

Answer 5

1. Aspiration of oropharyngeal secretions - MOST COMMON.
2. Haematogenous spread from a infected IV catheters.
3. Direct inoculation - thoracentesis.
4. Translocation from the GI tract.

Question 6

List the common sources of pathogens.

Answer 6

· Healthcare devices - infected biofilm in ETT.
· Environment - air, water, equipment.
· Transfer from patient to patient through healthcare workers - poor hand hygiene.

Question 7

How can HAP be prevented?

Answer 7

Hand hygiene, surveillance, isolation, semi-recumbent positions of 45 degrees.

Question 8

What is the aetiology of HAP?

Answer 8

· Aerobic gram negative bacteria:
 - Pseudomonas aeruginosa. 
 - E coli. 
 - Klebsiella pneumoniae. 
· MRSA. 

· Patients exposed to antimicrobials or to a healthcare facility prior to admission may be colonised with multi-drug resistant pathogens.
· MDR’s post common in ICUs.
· On the ward, patients may get strep pneumoniae and Legionella species.

Question 9

List the common risk factors related to HAP.

Answer 9

· Poor infection control/hand hygiene. 
· Intubation and mechanical ventilation. 
· Head of bed at <30 degree angle. 
· Poor oral hygiene. 
· Reintubation.

Question 10

List the common signs and symptoms related to HAP.

Answer 10

· Productive cough with thick yellow or green sputum. 
· Fever. 
· Dyspnoea. 
· Pleuritic pain. 
· Abnormal auscultatory findings.
· Tachycardia.

Question 11

What abnormal auscultatory findings would you find?

Answer 11

· Asymmetric chest expansion.
· Diminished resonance - ‘99’.
· Crackles.

Question 12

A diagnosis of HAP / VAP requires what?

Answer 12

A diagnosis of HAP / VAP requires positive imaging plus 2 of 3 clinical features:

· Fever greater than >38°C or less than 36°C.
· Leucocytosis or leukopenia.
· Purulent tracheal secretions and decreased partial pressure of oxygen in arterial blood (PaO2).

Question 13

What investigations would you request if you suspected a patient had HAP?

Answer 13

· CXR.
· FBC - raised WBCs.
· Oxygen saturations. 
· Sputum cultures. 
· ABG. 
· CRP, procalcitonin. 
· Pulse oximetry.

Question 14

Differentials?

Answer 14

· Cardiogenic pulmonary oedema - heart failure symptoms. 
· ARDS. 
· Pleural effusion. 
· PE. 
· Atelectasis. 
· Lung cancer.

Question 15

What are the treatment options before and after culture results?

Answer 15

· Before culture results - IV empirical abx therapy.

· After culture results - IV pathogen-directed abx therapy.

Question 16

Suggest some low risk complications.

Answer 16

· Empyema or lung abscess.
· SIRS or sepsis with multi-organ failure.
· PE/infarction.
· C diff colitis due to broad-spectrum abx use.