What is the recommended management approach for a suspected case of hospital-acquired pneumonia in an adult or geriatric patient with possible underlying health conditions?

Hospital-Acquired Pneumonia: Sample Referral Note to Infectious Disease Consultant

Patient Demographics and Clinical Context

• Document patient age, admission date, and number of days hospitalized prior to pneumonia onset (HAP defined as pneumonia occurring ≥48 hours after admission) 1
• Include relevant comorbidities: chronic lung disease, diabetes, immunosuppression, recent surgery, or prior endotracheal intubation 2
• Note recent antibiotic exposure within past 90 days and specific agents used 1

Clinical Presentation and Severity Assessment

• Record vital signs at presentation: temperature, respiratory rate, heart rate, blood pressure, oxygen saturation, and FiO₂ requirement 1
• Document mental status changes or altered consciousness 1
• Note presence of septic shock requiring vasopressors or mechanical ventilation requirement 1
• Include CURB-65 or PSI score if calculated, though these are primarily for community-acquired pneumonia 3

Radiographic Findings

• Specify chest imaging results: presence of new or progressive infiltrate, lobar consolidation pattern, cavitary lesions, or pleural effusion 2
• Note that 35% of clinically suspected HAP cases may lack radiological confirmation when objective criteria are applied 2

Microbiological Data

• Document respiratory specimen collection: sputum Gram stain and culture results, including specific organisms isolated and antimicrobial susceptibilities 2, 4
• Include blood culture results if obtained 1
• Note that only 24.7% of HAP patients typically have sputum obtained for culture, and bacterial pathogens are identified in approximately 49% of those samples 2
• Common HAP pathogens include: Pseudomonas aeruginosa, Staphylococcus aureus (including MRSA), Enterobacter species, Acinetobacter, and Klebsiella pneumoniae 5, 2

Risk Factors for Multidrug-Resistant Organisms

• MRSA risk factors: prior IV antibiotic use within 90 days, known MRSA colonization, healthcare setting with >20% MRSA prevalence, or post-influenza pneumonia 1, 6
• Pseudomonas risk factors: structural lung disease (bronchiectasis, cystic fibrosis), recent hospitalization with IV antibiotics, or prior P. aeruginosa isolation 1, 5

Current Antibiotic Regimen

• Specify current empiric therapy: most commonly piperacillin-tazobactam (57.2% of cases) or co-amoxiclav (12.5% of cases) 2
• Document date/time of antibiotic initiation and duration of therapy to date 1
• Note clinical response to current regimen: improvement, stability, or deterioration 1

Laboratory Parameters

• Include white blood cell count, C-reactive protein, procalcitonin if available 2
• Document renal function (creatinine clearance) as this affects antibiotic dosing 7
• Note inflammatory marker trends: radiologically confirmed HAP is associated with higher inflammatory markers 2

Specific Consultation Questions

• Request guidance on antibiotic selection based on local antibiogram and patient-specific risk factors 1, 6
• Ask about need for combination therapy, particularly for P. aeruginosa where monotherapy is associated with rapid resistance development and high clinical failure rates 5
• Inquire about optimal treatment duration (typically 7-14 days for nosocomial pneumonia) 7
• Request recommendations for de-escalation strategy once culture results available 6

Critical Pitfalls to Avoid in Referral

• Do not delay antibiotic initiation while awaiting consultation, as inappropriate initial therapy increases mortality 4, 6
• Avoid assuming all HAP requires broad-spectrum coverage without assessing specific risk factors for MDR organisms 6
• Do not overlook the possibility of alternative diagnoses, as HAP may be over-diagnosed in 35% of cases when strict radiological criteria are applied 2