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Semin Respir Crit Care Med 2009; 30(1): 086-091
DOI: 10.1055/s-0028-1119812
© Thieme Medical Publishers

Prevention Strategies for Healthcare-Associated Pneumonia

Lee E. Morrow1
  • 1Division of Pulmonary, Critical Care, and Sleep Medicine, Creighton University Medical Center, Omaha, Nebraska
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Publication History

Publication Date:
06 February 2009 (online)

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ABSTRACT

Healthcare-associated pneumonia (HCAP) represents one of the largest subsets of patients with pneumonia. Based on epidemiological projections for the aging U.S. population, the number of hospitalizations for HCAP is expected to increase exponentially for the next several decades. The unique risk factors for colonization with resistant pathogens in these patients provide multiple opportunities for HCAP prevention. However, our current understanding of the most effective prevention measures is woefully inadequate and constitutes an extrapolation from studies done in community-acquired and hospital-acquired pneumonia patients. This review explores common prevention strategies that may be applicable to HCAP, highlights areas of controversy that require further study, and describes several areas of ongoing novel investigation.

KEYWORDS

Pneumonia - cross-infection - prevention and control - nursing homes

REFERENCES

  • 1 Hospital-Acquired Pneumonia Guideline Committee of the 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;  171 388-416
    CrossrefPubMedGoogle Scholar
  • 2 Kollef M H. Inadequate antimicrobial treatment: an important determinant of outcome for hospitalized patients.  Clin Infect Dis. 2000;  31 S131-S138
    CrossrefPubMedGoogle Scholar
  • 3 Luna C M, Vujacich P, Niederman M S et al.. Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia.  Chest. 1997;  111 676-685
    CrossrefPubMedGoogle Scholar
  • 4 Kollef M H, Sherman G, Ward S, Fraser V J. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients.  Chest. 1999;  115 462-474
    CrossrefPubMedGoogle Scholar
  • 5 Iregui M, Ward S, Sherman G, Fraser V J, Kollef M H. Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia.  Chest. 2002;  122 262-268
    CrossrefPubMedGoogle Scholar
  • 6 Cosgrove S E, Kaye K S, Eliopoulous G M, Carmeli Y. Health and economic outcomes of the emergence of third-generation cephalosporin resistance in Enterobacter species.  Arch Intern Med. 2002;  162 185-190
    CrossrefPubMedGoogle Scholar
  • 7 Guay D RP. Guidelines for the management of adults with healthcare-associated pneumonia: implications for nursing facility residents.  Consult Pharm. 2006;  21 719-725
    PubMedGoogle Scholar
  • 8 Fujitani S, Yu V L. A new category—healthcare-associated pneumonia: a good idea but problems with its execution.  Eur J Clin Microbiol Infect Dis. 2006;  25 627-631
    CrossrefPubMedGoogle Scholar
  • 9 Micek S T, Kollef K E, Reichley R M, Roubinian N, Kollef M H. Healthcare-associated pneumonia and community-acquired pneumonia: a single center experience.  Antimicrob Agents Chemother. 2007;  51 3568-3573
    CrossrefPubMedGoogle Scholar
  • 10 Kollef M H, Shorr A, Tabak Y P, Gupta V, Liu L Z, Johannes R S. Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia.  Chest. 2005;  128 3854-3862
    CrossrefPubMedGoogle Scholar
  • 11 Centers for Disease Control . Guidelines for preventing health-care-associated pneumonia, 2003 recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee.  Respir Care. 2004;  49 926-939
    PubMedGoogle Scholar
  • 12 Brooks K, Whitten S, Quigley D. Reducing the incidence of ventilator-associated pneumonia.  J Healthc Qual. 1998;  20 14-19
    PubMedGoogle Scholar
  • 13 Zack J E, Garrison T, Trovillion E et al.. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia.  Crit Care Med. 2002;  30 2407-2412
    CrossrefPubMedGoogle Scholar
  • 14 Garner J S. Guideline for isolation precautions in hospitals: the Hospital Infection Control Practices Advisory Committee.  Infect Control Hosp Epidemiol. 1996;  17 53-80
    CrossrefPubMedGoogle Scholar
  • 15 Boyce J M, Pittet D. Healthcare Infection Control Practices Advisory Committee: HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force . Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America.  MMWR Recomm Rep. 2002;  51(RR-16) 1-45 , quiz CE1-4
    PubMedGoogle Scholar
  • 16 Pittet D, Hugonnet S, Harbarth S et al.. Effectiveness of a hospital-wide program to improve compliance with hand hygiene.  Lancet. 2000;  356 1307-1312
    CrossrefPubMedGoogle Scholar
  • 17 Sehulster L, Chinn R Y. CDC; HICPAC . Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICAC).  MMWR Recomm Rep. 2003;  52(RR-10) 1-42
    PubMedGoogle Scholar
  • 18 Food and Drug Administration .Enforcement Priorities for Single-Use Devices Reprocessed by Third Parties and Hospitals. Rockville, MD; US DHHS, FDA 2000
    Google Scholar
  • 19 van Grafhorst J P, Foudraine N A, Nooteboom F, Crombach W H, Oldenhof N J, van Doorne H. Unexpected high risk of contamination with Staphylococci species attributable to standard preparation of syringes for continuous intravenous drug administration in a simulation model in intensive care units.  Crit Care Med. 2002;  30 833-836
    CrossrefPubMedGoogle Scholar
  • 20 Trick W E, Weinstein R A, DeMarais P L et al.. Comparison of routine glove use and contact-isolation precautions to prevent transmission of multidrug-resistant bacteria in a long-term care facility.  J Am Geriatr Soc. 2004;  52 2003-2009
    CrossrefPubMedGoogle Scholar
  • 21 Osono E, Takahashi M, Kuihara S et al.. Effects of “isolating hemodialysis” on prevention of methicillin-resistant Staphylococcus aureus cross-infection in a hemodialysis unit.  Clin Nephrol. 2000;  54 128-133
    PubMedGoogle Scholar
  • 22 Kotilainen P, Routamaa M, Peltonen R et al.. Eradication of methicillin-resistant Staphylococcus aureus from a health center ward and associated nursing home.  Arch Intern Med. 2001;  161 859-863
    CrossrefPubMedGoogle Scholar
  • 23 Silverblatt F J, Tibert C, Mikolich D et al.. Preventing the spread of vancomycin-resistant enterococci in a long-term facility.  J Am Geriatr Soc. 2000;  48 1211-1215
    PubMedGoogle Scholar
  • 24 Dear K, Holden J, Andres R, Tatham D. Vaccines for preventing pneumococcal infection in adults.  Cochrane Database Syst Rev. 2003;  4 CD000422
    PubMedGoogle Scholar
  • 25 Fisman D N, Abrutyn E, Spaude K A, Kim A, Kirchner C, Daley J. Prior pneumococcal vaccination is associated with reduced death, complications, and length of stay among hospitalized adults with community-acquired pneumonia.  Clin Infect Dis. 2006;  42 1093-1101
    CrossrefPubMedGoogle Scholar
  • 26 Christenson B, Hedlund J, Lundbergh P, Ortqvist A. Additive preventive effect of influenza and pneumococcal vaccines in elderly persons.  Eur Respir J. 2004;  23 363-368
    CrossrefPubMedGoogle Scholar
  • 27 Vila-Corcoles A, Ochoa-Gondar O, Llor C, Hospital I, Rodriguez T, Gomez A. Protective effect of pneumococcal vaccine against death by pneumonia in elderly subjects.  Eur Respir J. 2005;  26 1086-1091
    CrossrefPubMedGoogle Scholar
  • 28 Janssens J P, Krause K H. Pneumonia in the very old.  Lancet Infect Dis. 2004;  4 112-124
    CrossrefPubMedGoogle Scholar
  • 29 Whitney C G, Farley M M, Hadler J et al.. Decline in invasive pneumococcal disease after the introduction of protein-polysaccharide conjugate vaccine.  N Engl J Med. 2003;  348 1737-1746
    CrossrefPubMedGoogle Scholar
  • 30 Ortqvist A, Hedlund J, Burman L A et al.. Randomized trial of 23-valent pneumococcal capsular polysaccharide vaccine in prevention of pneumonia in middle-aged and elderly people: Swedish Pneumococcal Vaccination Study Group.  Lancet. 1998;  351 399-403
    CrossrefPubMedGoogle Scholar
  • 31 Potter J, Stott D J, Roberts M A et al.. Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients.  J Infect Dis. 1997;  175 1-6
    PubMedGoogle Scholar
  • 32 Carman W F, Elder A G, Wallace L A et al.. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomized controlled trial.  Lancet. 2000;  355 93-97
    CrossrefPubMedGoogle Scholar
  • 33 Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP).  MMWR Recomm Rep. 1997;  46(No. RR-8) 1-24
    PubMedGoogle Scholar
  • 34 Hutt E, Kramer A M. Evidence-based guidelines for management of nursing home-acquired pneumonia.  J Fam Pract. 2002;  51 709-716
    PubMedGoogle Scholar
  • 35 Loeb M, McGeer A, McArthur M, Walter S, Simor A E. Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities.  Arch Intern Med. 1999;  159 2058-2064
    CrossrefPubMedGoogle Scholar
  • 36 Fine M J, Smith M A, Carson C A et al.. Efficacy of pneumococcal vaccination in adults: a meta-analysis of randomized controlled trials.  Arch Intern Med. 1994;  154 2666-2677
    PubMedGoogle Scholar
  • 37 Ortqvist A, Hedlund J, Burman L et al.. Randomized trial of 23-valent pneumococcal capsular polysaccharide vaccine in prevention of pneumonia in middle-aged and elderly people.  Lancet. 1998;  351 399-403
    CrossrefPubMedGoogle Scholar
  • 38 Koivula I, Sten M, Leinonen M, Makela P H. Clinical efficacy of pneumococcal vaccine in the elderly: a randomized, single-blind population-based trial.  Am J Med. 1997;  103 281-290
    CrossrefPubMedGoogle Scholar
  • 39 Gross P A, Hermogenes A W, Sacks H S, Lau J, Levandowski R A. The efficacy of influenza vaccine in elderly persons.  Ann Intern Med. 1995;  123 518-527
    PubMedGoogle Scholar
  • 40 Muszkat M, Greenbaum E, Ben Yehuda A et al.. Local and systemic immune response in nursing-home elderly following intranasal or intramuscular immunization with inactivate influenza vaccine.  Vaccine. 2003;  21 1180-1186
    CrossrefPubMedGoogle Scholar
  • 41 Olive K E, Berk S L. Infections in the nursing home.  Clin Geriatr Med. 1992;  8 821-834
    PubMedGoogle Scholar
  • 42 Naqvi S B, Collins A J. Infectious complications in chronic kidney disease.  Adv Chronic Kidney Dis. 2006;  13 199-204
    CrossrefPubMedGoogle Scholar
  • 43 Marrie T J. Pneumonia in the long-term-care facility.  Infect Control Hosp Epidemiol. 2002;  23 159-164
    CrossrefPubMedGoogle Scholar
  • 44 Drakulovic M B, Torres A, Bauer T T, Nicolas J M, Nogue S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomized trial.  Lancet. 1999;  354 1851-1858
    CrossrefPubMedGoogle Scholar
  • 45 Torres A, Serra-Batlles J, Ros E et al.. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position.  Ann Intern Med. 1992;  116 540-543
    CrossrefPubMedGoogle Scholar
  • 46 Celis R, Torres A, Gatell J M, Almela M, Rodriguez-Roisin R, Augusti-Vidal A. Nosocomial pneumonia: a multivariate analysis of risk and prognosis.  Chest. 1988;  93 318-324
    PubMedGoogle Scholar
  • 47 Gillick M R. Rethinking the role of tube feeding in patients with advanced dementia.  N Engl J Med. 2000;  342 206-210
    CrossrefPubMedGoogle Scholar
  • 48 Loeb M B, Backer M, Eady A, Walker-Dilks C. Interventions to prevent aspiration pneumonia in older adults: a systematic review.  J Am Geriatr Soc. 2003;  51 1018-1022
    CrossrefPubMedGoogle Scholar
  • 49 Quagliarello V, Ginter S, Han L, Van Ness P, Allore H, Tinetti M. Modifiable risk factors for nursing home-acquired pneumonia.  Clin Infect Dis. 2005;  40 1-6
    CrossrefPubMedGoogle Scholar
  • 50 Leder S B. Videofluoroscopic evaluation of aspiration with visual examination of the gag reflex and velar movement.  Dysphagia. 1997;  12 21-23
    CrossrefPubMedGoogle Scholar
  • 51 Leder S B. Gag reflex and dysphagia.  Head Neck. 1996;  18 138-141
    CrossrefPubMedGoogle Scholar
  • 52 Marik P E, Kaplan M A. Aspiration pneumonia and dysphagia in the elderly.  Chest. 2003;  124 328-336
    CrossrefPubMedGoogle Scholar
  • 53 Yoneyama T, Yoshida M, Ohrui T et al.. Oral care reduces pneumonia in older patients in nursing homes.  J Am Geriatr Soc. 2002;  50 430-433
    CrossrefPubMedGoogle Scholar
  • 54 Chlebicki M P, Safdar N. Topical chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis.  Crit Care Med. 2007;  35 595-602
    CrossrefPubMedGoogle Scholar
  • 55 Bergmans D C, Bonten M J, Gaillard C A et al.. Prevention of ventilator-associated pneumonia by oral decontamination: a prospective, randomized, double-blind, placebo-controlled study.  Am J Respir Crit Care Med. 2001;  164 382-388
    PubMedGoogle Scholar
  • 56 Laheij R J, Sturkenboom M C, Hassing R J, Dieleman J, Stricker B H, Jansen J B. Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs.  JAMA. 2004;  292 1955-1960
    PubMedGoogle Scholar
  • 57 Forestier C, Guelon D, Cluytens V, Gillart T, Sirot J, de Champs C. Oral probiotic and prevention of Pseudomonas aeruginosa infections: a randomized, double-blind, placebo-controlled pilot study in intensive care unit patients.  Crit Care. 2008;  12 R69
    CrossrefPubMedGoogle Scholar
  • 58 Ardigo D, Valtuena S, Zavaroni I, Baroni M C, Delsignore R. Pulmonary complications in diabetes mellitus: the role of glycemic control.  Curr Drug Targets Inflamm Allergy. 2004;  3 455-458
    CrossrefPubMedGoogle Scholar
  • 59 Nuorti J P, Butler J C, Farley M M et al.. Cigarette smoking and invasive pneumococcal disease. Active Bacterial Core Surveillance Team.  N Engl J Med. 2000;  342 681-689
    Google Scholar
  • 60 van de Garde E M, Souverein P C, Hak E, Deneer V H, van den Bosch J M, Leufkens H G. Angiotensin-converting enzyme inhibitor use and protection against pneumonia in patients with diabetes.  J Hypertens. 2007;  25 235-239
    CrossrefPubMedGoogle Scholar
  • 61 Teramoto S, Yamamoto H, Yamaguchi Y et al.. ACE inhibitors prevent aspiration pneumonia in Asian, but not Caucasian, elderly patients with stroke.  Eur Respir J. 2007;  29 218-219
    PubMedGoogle Scholar

Lee E MorrowM.D. M.Sc. 

Division of Pulmonary, Critical Care, and Sleep Medicine, Creighton University Medical Center

601 North 30th St., Ste. #3820, Omaha, NE 68131

Email: lmorrow@creighton.edu

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