Nosocomial, d. H. hospital-acquired pneumonia develop at least 48 hours after admission. The most common pathogens are gram-negative rods and Staphylococcus aureus; against antibiotic-resistant organisms are a major cause for concern. Symptoms and complaints include fatigue, fever, chills, rigors, cough, dyspnea and chest pain, but in mechanically ventilated patients, the pneumonia can usually manifested as deterioration of oxygenation and proliferation of tracheal secretions. The diagnosis is suspected because of the clinical picture and chest x-ray findings and confirmed by blood cultures or bronchoscopy material derived from the lower respiratory tract. Treatment is with antibiotics. The overall prognosis is poor, partly due to existing comorbidities.
include hospital-acquired pneumonia ventilator-associated pneumonia and postoperative as well as those that develop in non-ventilated inpatients.
Nosocomial, d. H. hospital-acquired pneumonia develop at least 48 hours after admission. The most common pathogens are gram-negative rods and Staphylococcus aureus; against antibiotic-resistant organisms are a major cause for concern. Symptoms and complaints include fatigue, fever, chills, rigors, cough, dyspnea and chest pain, but in mechanically ventilated patients, the pneumonia can usually manifested as deterioration of oxygenation and proliferation of tracheal secretions. The diagnosis is suspected because of the clinical picture and chest x-ray findings and confirmed by blood cultures or bronchoscopy material derived from the lower respiratory tract. Treatment is with antibiotics. The overall prognosis is poor, partly due to existing comorbidities. include hospital-acquired pneumonia ventilator-associated pneumonia and postoperative as well as those that develop in non-ventilated inpatients. Etiology The most common cause is a microaspiration of bacteria that colonize the oropharynx and upper airway of critically ill patients. The colonization of the lungs by bacteremia or inhalation of contaminated aerosols (d. H. Airborne particles that Legionella sp, Aspergillus sp or influenza virus included) are less common causes (overview of pneumonia (pneumonia)). Risk factors Endotracheal intubation with mechanical ventilation represents the greatest overall risk; Ventilator-associated pneumonia account for> 85% of cases, and pneumonia occurs in 9-27% of ventilated patients. The highest risk of VAP occurs during the first 10 days of intubation. Endotracheal intubation breaks through the defense mechanisms of the respiratory tract, accessibility expectoration and the mucociliary clearance, and facilitates the microaspiration of bacteria-containing secretions that collect above the inflated blocking the tube. In addition, bacteria form a biofilm and tracheal tube, which protects them from antibiotics and immune system of their host. Among the risk factors in patients nonintubated include previous antibiotic treatment, high gastric pH (due to prevention or treatment with H2Blockern or proton pump inhibitors of stress ulcers) and simultaneously present insufficiency of heart, lung, liver or kidney. The main risk factors for the development of postoperative pneumonia are age> 70 years, abdominal or thoracic surgery and Pflegebedürftigkeit.Krankheitserreger the causative pathogens and antibiotic resistance vary significantly between different institutions and can be surrounded in a clinic rapid changes subject (e. B. from month to Month). In general, the most important pathogen Pseudomonas aeruginosa, methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus (MRSA). Other important pathogens include Gram-negative enteric bacteria (mainly Enterobacter sp., Klebsiella pneumoniae, Escherichia coli, Serratia marcescens, Proteus spp., And Acinetobacter sp.). Methicillin-sensitive S. aureus, Streptococcus pneumoniae and Haemophilus influenzae are most frequently involved in pneumonia, which develop within 4-7 days after admission, while P. aeruginosa, MRSA and Gram-negative intestinal bacteria with increasing intubation or hospital length of stay and more often the cause become. A previous antibiotic treatment (within the previous 90 days) increases the likelihood of multi bacterial infections and antibiotic-resistant microorganisms, especially methicillin-resistant strains of S. aureus, and Pseudomonas, considerably infection with a resistant microorganism worsen mortality and morbidity significantly. Other risk factors for polymicrobial infection and antibiotic-resistant organisms are Current hospitalized for ? 5 days High incidence of antibiotic resistance in society, in the hospital or special hospital ward hospitalization for ? 2 days within the last 90 days stay in a care facility or extended care facility Outpatient Infusion Therapy (including antibiotics) dialysis outpatient wound care family member with an infection due to antibiotic-resistant pathogen immunosuppressive disease or therapy because of these factors, however, may increase the risk of polymicrobial and antibiotic-resistant organisms are overestimated and lead to excessive use of broad-spectrum antibiotics. High-dose corticosteroids increase the risk of infections by Pseudomonas Legionellaund. Symptoms and signs The symptoms in nonintubated patients generally the same as with community-acquired pneumonia (pneumonia acquired Ambulant: symptoms and complaints) and include malaise, fever, chills, rigors, cough, dyspnea and chest pain. Pneumonia in critically ill, mechanically ventilated patients typically more likely to cause fever and increase in breathing or heart rate or change in respiratory parameters such as proliferation of purulent tracheal secretions or worsening hypoxemia. Diagnostic chest X-ray and clinical criteria (limited accuracy) Sometimes bronchoscopy, blood cultures, the diagnosis is poor. In clinical practice, a stationary acquired pneumonia is often suspected based on a newly occurring infiltrate in the chest X-ray, which to diagnose new onset symptoms or signs (eg., Fever, increased secretions, worsening hypoxemia) was induced leukocytosis. However, no symptom or radiographic findings is sufficiently sensitive or specific for diagnosis because they can all be caused by atelectasis, pulmonary embolism or pulmonary edema and may occur as part of symptoms of ARDS. Alternative diagnoses should be sought, especially in patients who have a risk score <6 for pneumonia (see table: fo risk index hospital-acquired pneumonia). fo risk index hospital-acquired pneumonia factor points Temperature (° C) ? 36.5 ? 38.4 and 0 ? 38.5 ? 38.9 and 1 ? 39 and ? 36 2 leukocytes in the blood (ul) ? 400 0 and ? 11,000 0 <4000 or> 11,000 1 Volume forms ? 50% 1 0 tracheal No non-suppurative 1 Purulent 2 Oxygenation: PaO 2 / FiO 2, mmHg > 240 or ARDS 0 ? 240 and no ARDS 2 radiography Pulmonary infiltrates None 0 Diffuse (or incomplete) infiltrates 1 Local infiltrations 2 progression of infiltrates * No 0 progression (heart failure and ARDS excluded) 2 growth of pathogenic bacteria on tracheal aspirate culture * No, rare, or slight growth 0 Patchy Growth 1 Same as bacteria on Gram stain 1 * apply criteria that 72 hours after the initial diagnosis. Result ? 6 suggests hospital-acquired pneumonia. Result <6 suggests an alternative diagnosis. PaO2 / FiO2 = ratio of arterial O2 pressure to the fraction of inspired O2; ARDS = acute respiratory distress syndrome. Adapted from Singh N, P Rogers, Atwood CW, et al: empirical antibiotic short-term treatment of patients with pulmonary infiltrates in the intensive care unit. American Journal of Respiratory and Critical Care Medicine 162: 505-511, 2000. The importance of Gram stains and cultures of tracheal secretions aspirated is of uncertain benefit, because the samples can be contaminated by bacteria of the resident flora, and a positive culture can express be an infection, but does not. Samples bronchoscopy recovered from the lower airways for quantitative cultures provide reliable results that can distinguish between colonization and infection. Information obtained from bronchoscopic sampling, reduce the use of antibiotics and help with the transition from wider to narrower antibiotic shielding. However, no better results has been demonstrated so far. Measurement of inflammatory mediators in bronchoalveolar lavage have proven to be unreliable. An increase of the serial serum procalcitonin levels can identify patients with impending degradation. The only method by which both pneumonia and the pathogens are based can be reliably identified, is a positive cultural detection of pathogens from pleural fluid (obtained via a thoracentesis in a patient with pleural effusion) Blood cultures are relatively specific, when a respiratory pathogens identified was, but they are insensitive. Prognosis The mortality of hospital-acquired pneumonia varies in spite of available effective antibiotics by 25-50%. However, not every mortality due to pneumonia itself; Many of the deaths are related other underlying disease. The adequacy of initial antimicrobial therapy significantly improved the prognosis. Infection with antibiotic-resistant gram-negative or gram-positive bacteria worsens the prognosis. Treatment empirically chosen antibiotic against resistant organisms is HAP suspected, the patient, the treatment with antibiotics, which are empirically selected based on susceptibility testing risk factors for antibiotic-resistant pathogens start early onset pneumonia occurs within the first 4 days of hospitalization. Late-onset pneumonia occurs after ? 5 days of hospitalization. Recommendations for patients with early onset of HAP without risk factors for antibiotic resistant organisms include one of the following: (. E.g., levofloxacin, moxifloxacin, gemifloxacin) ceftriaxone A respitatorisches fluoroquinolone ampicillin / sulbactam ertapenem The dosage depends (on renal function see Table: Usual doses of the commonly prescribed antibiotics). Among the recommendations for patients with late-onset disease or with risk factors for antibiotic-resistant organisms include triple therapy with two drugs with activity against Pseudomonas and one drug with activity against MRSA: An anti-Pseudomonas cephalosporin (cefepime or ceftazidime) or an anti-Pseudomonas carbapenem (imipenem, meropenem ) or a ?-lactam / ?-lactamase inhibitor (piperacillin / tazobactam) an anti Pseudomonas fluoroquinolone (ciprofloxacin or levofloxacin) or an aminoglycoside (amikacin, gentamicin, or tobramycin) linezolid or vancomycin While the undifferentiated use of antibiotics is a major cause for the development of is antibiotic resistance, the scope of the initial empirical antibiotic is a mainstay for a good result. Therefore, treatment with a broad-spectrum antibiotic should be started, which is then replaced by the closest possible based on clinical evaluations and the results of Kuluren and the antibiotic Empfänglichkeitstests. Alternative strategies that have been used to limit resistance, but have proved ineffective, discontinuation of antibiotic see table include 72 h in patients in which the pneumonia risk index (s. Fo risk index hospital-acquired pneumonia ) has improved to <6, and the routine change of antibiotics empirically used (eg. as every 3-6 months). Prevention Among the cases of HAP, the preventive measures that focus on VAP are the most effective. The positioning of the patient in a semi-upright or upright position reduces the aspiration and pneumonia risk compared to lying positions and is the safest and most effective Präventationsmethode. Non-invasive ventilation techniques in which a continuous positive airway pressure (CPAP) or a biphasic positive airway pressure (BiPAP) is used to prevent the opening of the defense mechanisms of the respiratory system that occurs in endotracheal intubation, and make intubation in some patients unnecessary. Continuous aspiration of subglottic secretions using a specially-designed for endotracheal tube is connected to an exhausting device seems to reduce the risk of aspiration. Selective disinfection of the oropharynx is controversial (with topical gentamicin, colistin, chlorhexidine or Vancomycinsalben, or a combination thereof) or the entire GI tract (with polymyxin, an aminoglycoside or quinolone and either nystatin or amphotericin B), due to concern for resistant strains and because the disinfection, although it reduces the occurrence of VAP, has not been shown to be effective in reducing the mortality. That regularly removed cultural smears and routine replacement of the breathing tubes or tracheal tubes reduce VAP, could not be shown. Ergo-spirometry is recommended to prevent postoperative pneumonia. Ventilator-associated include important items Hospital-acquired pneumonia and postoperative pneumonia as well as those developed in non-ventilated patients who were hospitalized for at least 48 hours. Mechanical ventilation is the most important risk factor for HAP. Probable pathogens are different from those that cause community-acquired pneumonia and require initial empirical antibiotic therapy, which is active against antibiotic-resistant organisms. Diagnosis is difficult, the culture of a potential pathogen of pleural fluid or blood is the most specific method. Patients should re-examined several days after treatment and antibiotics on the basis of available cultures and clinical data is changed.