British Society For Antimicrobial Chemotherapy Launch The First Evidence-based UK Guidelines To Tackle Hospital-acquired Pneumonia (HAP)

Main Category: MRSA / Drug Resistance
Also Included In: Infectious Diseases / Bacteria / Viruses
Article Date: 02 Jul 2008 - 2:00 PDT

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The British Society for Antimicrobial Chemotherapy (BSAC) published the first evidence-based UK guidelines to address the management of hospital-acquired pneumonia (HAP) which is the most common hospital acquired infection in intubated1 patients increasing mortality by up to 75%2. Following four years of data analysis, the guidance has been developed to tackle a range of issues including prevention, diagnosis and treatment of HAP in order to reduce the inconsistencies in its management across the UK - which currently results in thousands of preventable cases each year.

HAP is an infection of the lungs, which develops after a minimum of 48 hours after hospital admission3,4 and can significantly extend hospital stays5. The cost to the healthcare system of treating hospital acquired infections is as much as £1 billion per year6 and HAP, as the most common HAI in intubated patients1, has contributed significantly to this growing burden on the NHS. Yet until now, guidelines on the most appropriate treatment and management of HAP have been fragmented and presented conflicting recommendations, which has resulted in a low level of implementation. This has led to severe consequences for the patients themselves, their families and the NHS.

Commenting on the publication of the guidelines, Dr Robert Masterton, Executive Medical Director, The Ayr Hospital says, "Hospital acquired infections have a significant impact on patients' health and life expectancy and are a huge drain on healthcare resources. The new BSAC guidance has been developed from all the available data in the area, to offer a comprehensive and cohesive approach to management, taking into consideration all aspects of care. We strongly recommend that these guidelines are consistently implemented in practice in order to ensure that real improvements are made in the prevention and overall management of HAP."

Patients at high risk of HAP include the very old and very young, patients with diseases or undergoing treatments which suppress the immune system and those being treated with invasive procedures and medical devices4,7. The flu-like symptoms can strike patients suddenly and include fever, aches and pains, and loss of appetite. Patients nearly always have a cough, often with mucky sputum, and may experience pain in the side of the chest that can make breathing and coughing uncomfortable and / or reduced cough reflex8.

When HAP is caused by bacteria, treatment will always be with antibiotics. However, the increasing problem of antimicrobial resistance - largely due to the inappropriate use of antibiotics - has made its management more complicated and has led to a rise in hospital acquired infections as a whole9.

Dr Angela Galloway, Consultant Microbiologist, Royal Victoria Infirmary, Newcastle upon Tyne says, "A key driver in developing the guidelines was to minimise the number of preventable deaths from hospital acquired pneumonia due to any cause".

She continues: "The new guidelines set out the importance of prevention, diagnosis and early treatment ensuring that the right antibiotic is used at the right time. These guidelines should be used to develop local care pathways which should be incorporated into standard clinical practice. If this is achieved it will represent an important step forward in the management of HAP."

Key Guideline Recommendations

The new guidelines recommend specific approaches to maximise the prevention of HAP, ensure correct and timely diagnosis and effective treatment:

Prevention:

The importance of educating staff on all preventative methods is highlighted and it is recommended that where possible healthcare professionals should opt for non-invasive (e.g. a face mask that improves oxygenation) rather than invasive assisted ventilation (e.g. a tube inserted down the throat), in order to prevent HAP.10

Diagnosis:

A holistic approach to diagnosis should be taken, using radiological and microbiological tests to support clinical decision making.10

Treatment:

In current practice, healthcare professionals may wait for the results of diagnostic tests before choosing which antibiotic to treat with - yet this process promotes the emergence of antibiotic resistance11 which therefore increases the patient's risk of mortality. The HAP guidelines recommend the need to treat 'hard and fast' with an appropriate antibiotic. They advise that until the causative bacterium is known, an empirical broad spectrum antibiotic which is effective against the most common bacteria in that particular hospital or unit should be used. In all cases it is recommended that the local problem bacteria need to be taken into account when choosing an antibiotic.10

Once the source of the HAP has been confirmed the guidelines recommend switching to an antibiotic that targets the specific bacteria causing the infection. The use of a single antibiotic is recommended as there are no benefits in using combination therapy. Finally, treatment should not be continued for more than eight days as this has not demonstrated any benefits for patients and increases the risk of resistance.10

References

1. Rello J et al. Incidence, etiology and outcome of nosocomial pneumonia in ICU patients requiring percutaneous tracheotomy for mechanical ventilation. Chest 2003; 124;6: 2239 -2243

2. Garrard CS. The importance of nosocomial pneumonia in the ICU. Available at http://www.brit-thoracic.org.uk Last accessed April 5, 2007

3. Grossman RF and Fein A. Evidence-based assessment of diagnostic tests for ventilator-associated pneumonia. Chest. 2000; 117: 177s-181s

4. World Health Organization. Prevention of hospital-acquired infections - a practical guide. 2nd edition 2002

5. Boyce J, Potter-Bynoe G, Dziobek L et al. Nosocomial pneumonia in Medicare patients: hospital costs and reimbursement patterns under the prospective payment system. Arch Intern Med 1991; 151: 1109-1114

6. National Audit Office: Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England. 17th February 2000

7. DH Winning Ways. Working together to reduce healthcare associated infection in England. Report from the Chief Medical Officer. December 2003

8. British Lung Foundation Pneumonia fact sheet. Available at http://www.lunguk.org. Last accessed April 5, 2007

9. Barbosa TM and Levy SB. The impact of antibiotic use on resistance development and persistence. Drug Resistance Updates. 2000; 3:303-311

10. Masterton RG et al. Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy. Journal of Antimicrobial Chemotherapy. Available at: http://jac.oxfordjournals.org/cgi/content/full/dkn162 Last accessed 12th May 2008

11. Kollef MH et al, Strategies to prevent antimicrobial resistance in the intensive care unit. Crit Care Med 2005; 33: 8 1845-1853

British Society for Antimicrobial Chemotherapy