Update of the Treatment of Nosocomial Pneumonia in the ICU

Rafael Zaragoza; Pablo Vidal-Cortés; Gerardo Aguilar; Marcio Borges; Emili Diaz; Ricard Ferrer; Emilio Maseda; Mercedes Nieto; Francisco Xavier Nuvials; Paula Ramirez; Alejandro Rodriguez; Cruz Soriano; Javier Veganzones; Ignacio Martín-Loeches


Crit Care. 2020;24(383) 

In This Article

HAP Risk Factors

Traditionally, three kinds of risk factors for nosocomial pneumonia have been considered: patient-related, infection prevention-related and procedures-related. Patient-related factors are acute or chronic severe disease, coma, malnutrition, prolonged hospital length of stay, hypotension, metabolic acidosis, smoking and comorbidities (especially of the central nervous system but also chronic obstructive pulmonary disease (COPD), diabetes mellitus, alcoholism, chronic renal failure and respiratory insufficiency). Amongst risk factors related to infection prevention, those notable are deficient hand hygiene or inappropriate care of respiratory support devices. Finally, amongst factors related to procedures, administration of sedatives, corticosteroids and other immunosuppressants, prolonged surgical procedures (especially at thoracic or abdominal level) and prolonged/inappropriate antibiotic treatment are the most recognized factors.[13,38,45–47] More recent studies have observed an increased risk of nosocomial pneumonia in patients who receive gastric acid-modifying drugs during their admission (OR: 1.3 [1.1–1.4]).[48]

Given that there is no artificial airway, we can consider pneumonia in the patient who undergoes NIMV as a subtype of pneumonia in the non-ventilated patient. A prospective study analysed 520 patients who received NIMV. No statistically significant differences were found in terms of age, sex, severity or gas exchange parameters amongst those patients who presented nosocomial pneumonia and complication of NIMV and those who did not.[49]

A physiopathological approach for nosocomial pneumonia has been proposed in Figure 1.

Figure 1.

Physiopathological approach of progression of nosocomial pneumonia from wards to ICU. From green to red colour, the progression of the severity of nosocomial pneumonia is described independently of the area of hospital admission. vHAP shows the poorest outcome. HAP, hospital-acquired pneumonia; NV-ICUAP, non-ventilated acquired pneumonia; VAP, ventilator-acquired pneumonia; vHAP, ventilated hospital-acquired pneumonia