Hospital-acquired pneumonia causes

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Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D. ; Philip Marcus, M.D., M.P.H.

Overview

The majority of cases related to various gram-negative bacilli (52%) and S. aureus (19%). Others are Haemophilus spp. (5%). In the ICU results were S. aureus(17.4%), P. aeruginosa (17.4%), Klebsiella pneumoniae and Enterobacter spp. (18.1%), and Haemophilus influenzae (4.9%). Viruses -influenza and respiratory syncytial virus and, in the immunocompromised host, cytomegalovirus- cause 10-20% of infections.

Causes

Aerobic Gram Negative Pathogens

• Commonly polymicrobial
• Common microbial agents include:
  • Pseudomonas aeruginosa
  • Escherichia coli
  • Klebsiella pneumoniae
  • Acinetobacter

Gram-Positive Pathogens

• Staphylococcus aureus
• Methicillin resistant staphylococcus aureus (common in patients with diabetes mellitus, head trauma, and in ICU)

Elderly Population

• S. aureus
• Enteric gram-negative rods
• Streptococcus pneumoniae
• Pseudomonas

Ventilator-associated Pneumonia (VAP)

• The microbiologic flora responsible for VAP is different from that of the more common community-acquired pneumonia (CAP). In particular, viruses and fungi are uncommon causes in people who do not have underlying immune deficiencies.
• Though any microorganism that causes CAP can cause VAP, there are several bacteria which are particularly important causes of VAP because of their resistance to commonly used antibiotics. These bacteria are referred to as multidrug resistant (MDR).
• VAP has been classified into either early-onset pneumonia (EOP), if pneumonia develops within 96 hours of the patient’s admission to an ICU or intubation for mechanical ventilation, and late-onset pneumonia (LOP), if pneumonia develops after 96 hours of the patient’s admission to an ICU or intubation for mechanical ventilation.
• This categorization can be helpful to clinicians in initiating empiric antimicrobial therapy for cases of pneumonia, when the results of microbiologic diagnostic testing are not yet available.
• EOP has been associated usually with non-multi-antimicrobial-resistant microorganisms such as Escherichia coli, Klebsiella spp., Proteus spp., S. pneumoniae, H. influenzae, and oxacillin-sensitive S. aureus.
• On the other hand, LOP has been associated with Pseudomonas aeruginosa, oxacillin-resistant S. aureus, and Acinetobacter spp (strains that are usually multi-antibiotic-resistant).

The following is a list of the most MDR common pathogens associated with ventilator-associated pneumonia:

• Pseudomonas aeruginosa is the most common MDR gram-negative bacterium causing VAP. Pseudomonas has natural resistance to many antibiotics and has been known to acquire resistance to every antibiotic except for polymixin B. Resistance is typically acquired through upregulation or mutation of a variety of efflux pumps which pump antbiotics out of the cell. Resistance may also occur through loss of an outer membrane porin channel (OprD)
• Klebsiella pneumoniae has natural resistance to some beta-lactam antibiotics such as ampicillin. Resistance to cephalosporins and aztreonam may arise through induction of a plasmid-based extended spectrum beta-lactamase (ESBL) or plasmid-based ampC-type enzyme.
• Serratia marcescens has an ampC gene which can be induced by exposure to antibiotics such as cephalosporins. Thus, culture sensitivities may initially indicate appropriate treatment which fails due to bacterial response.
• Enterobacter as a group also have an inducible ampC gene. Enterobacter may also develop resistance by acquiring plasmids.
• Citrobacter also has an inducible ampC gene.
• Stenotrophomonas maltophilia often colonizes people who have endotracheal tubes or tracheostomies but can also cause pneumonia. It is often resistant to a wide array of antibiotics but is usually sensitive to co-trimoxazole.
• Acinetobacter are becoming more common and may be resistant to carbapenems such as imipenem and meropenem.
• Burkholderia cepacia is an important organism in people with cystic fibrosis and is often resistant to multiple antibiotics.
• Methicillin-resistant Staphylococcus aureus is an increasing cause of VAP. As many as fifty percent of Staphylococcus aureus isolates in the intensive care setting are resistant to methicillin. Resistance is conferred by the mecA gene.