Stat Consult • Oxygen therapy • Ranitidine
• Signs of infection • Decreased oxygenation • Unexplained hemodynamic instability
— Arterial oxygen saturation or arterial blood gas — Complete blood count, electrolytes, renal, liver function tests — Blood cultures — Sampling of lower-respiratory-tract secretions (LRTS) ■ Methods » Endotracheal aspirate » Bronchoalveolar lavage » Protected specimen brush ■ Evaluation » Gram stain » Cultures — Bronchoscopic bacteriologic strategy — Diagnostic thoracentesis if large effusion • If patients are not responding to initial empiric therapy, considerations include — Repeat sampling of LRTS — Change vascular-access catheters — Culture blood, catheter line tips, urine — Other radiologic procedures — Open lung biopsy
Lungs
Imaging studies
• Rales or bronchial breath sounds
• CXR (posteroanterior, lateral, decubitus) • Ultrasound • CT scan (chest, sinus, abdomen)
Factors not associated with increased risk
• Diabetes mellitus Complications
• Higher mortality • Longer hospital stays • Higher rate of malnutrition than community-acquired pneumonia History
• New-onset fever, purulent sputum, or increased cough • Dyspnea or tachypnea • Altered mental status in patients aged 70 years or older General symptoms
Making the diagnosis
• American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) recommendations — New or progressive lung infi ltrate on chest x-ray (CXR) plus two or more of: ■ Fever >38ºC (100.4ºF) ■ Leukocytosis or leukopenia ■ Purulent secretions — If acute respiratory distress syndrome present, suspect and test for nosocomial pneumonia if ■ Any one of above criteria ■ Unexplained hemodynamic instability ■ Deterioration of blood gases during ventilation Rule out • Community-acquired pneumonia • Extrapulmonary infection • Tracheobronchitis • Other pulmonary conditions • Heart failure ATS/IDSA testing overview
• Initial testing — CXR
Other diagnostic testing
• Consider nonbronchoscopic (quantitative) sampling if bronchoscopy not immediately available • Semiquantitative tracheal aspirate not as reliable as quantitative cultures • No sampling technique performed any better than clinical criteria alone • Biomarkers may be useful Empiric antibiotic therapy
• Begin empiric IV therapy immediately if high probability of pneumonia or evidence of sepsis, regardless of LRTS microscopy results • Switch to oral or enteral therapy if good clinical response and functioning intestinal tract • Antibiotic selection — Based on risk assessment for multidrug resistance (MDR) pathogens — Determined by local microbiology (including drug resistance), cost, availability and formulary restrictions
70 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com
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