Thank you for your interest in CCO content. As a guest, please complete the following information fields. These data help ensure our continued delivery of impactful education.
Become a member (or login)? Member benefits include accreditation certificates, downloadable slides, and decision support tools.
Associate Chief Medical Officer in Infectious Diseases
Jackson Health System
Professor of Infectious Diseases
Department of Medicine & Miami Transplant Institute
University of Miami Miller School of Medicine
Lilian Abbo, MD, FIDSA, has disclosed that she has received consulting fees from Ferring.
For me, the key to managing hospital-acquired bacterial pneumonia (HABP) and ventilator-associated bacterial pneumonia (VABP) is recognizing that hospitalized or ventilated patients are not a monolithic group. I spend my clinical time managing HABP and VABP in transplant patients, who are particularly vulnerable to having prolonged hospitalizations, immunosuppression, and polypharmacy. These patients differ from acute trauma or burn patients who are hospitalized or ventilated, but all are at risk for HABP or VABP. I am sharing my perspective on infection control in managing patients with HABP or VABP as part of a program that includes pharmacy and other clinical experience.
Know Your Patient
First—because not all HABPs and VABPs are the same—I always say that you need to look at the host. Who is the patient? What are the individual risk factors? To which antibiotics has this patient been exposed? What acute event is happening? For how long has this patient been in the hospital? Has this patient been on and off a ventilator?
You need to know the setting, as well as the host—looking at the whole patient. Does the patient have any other ports or central lines? Does the patient have any sacral decubitus ulcers? What else is going on with this patient? You need to know the setting, and you need to distinguish colonization vs infection.
Know Your Local Epidemiology
Second, you need to know the common pathogens in your hospital, area, and environment. In Miami, where I practice, many patients come from other countries already colonized with organisms. So, we swab our patients for airway colonization. Many nursing homes residents also arrive already colonized in some of our community hospitals. I need to know the local epidemiology. That’s my next pearl: Know the host, know the setting, and know the local epidemiology.
Tailor Your Treatment
The first marker I ask the lab to look at is carbapenem resistance in HABP/VABP. This is because, once the patient has been in the hospital for more than 48 hours, I need to think superbugs more than your regular pansusceptible microbes and use that to decide which broad-spectrum antibiotic to pick. You can’t kill everything with a big gun—you have to tailor and streamline. We don’t start everyone empirically on the new β-lactam inhibitors, but we do look at our algorithms. We start the patient on empiric therapy, and we streamline once we have the susceptibilities. The duration of therapy also is key because you need to look at the individual patient. We treat most patients for 7 days, but it must be individualized.
As infectious disease physicians, we look at prevention and management, and we work very closely with the lab, which no other specialty does. We go to the micro lab, we work collectively, and we look at what is best for the individual—it is a form of precision medicine. It is easy these days to have broad, evidence-based guidelines, but we always need to look at the individual. Examine the patient you have in front of you. Look at their individual risk factors, and figure out the best treatment, the right dose, and the right duration for that patient, because not all of us have the same kidney function. Not all of us have the same comorbidities. Guidelines are great, but you have to bring it back to that individual.
What is the most common resistance seen in your patients with HABP/VABP? Answer the polling question and join the conversation by posting a comment in the discussion section.