Adult patients with nosocomial pneumonia: epidemiology, diagnosis, and treatment

Klaus Dalhoff, Santiago Ewig, Marianne Abele-Horn, Stefan Andreas, Torsten T Bauer, Heike von Baum, Maria Deja, Petra Gastmeier, Sören Gatermann, Herwig Gerlach, Beatrice Grabein, Gert Höffken, Winfried Kern, Evelyn Kramme, Christoph Lange, Joachim Lorenz, Konstantin Mayer, Irit Nachtigall, Matthias Pletz, Gernot Rohde, Simone Rosseau, Bernhard Schaaf, Reiner Schaumann, Dirk Schreiter, Hartwig Schütte, Harald Seifert, Helmut Sitter, Claudia Spies, Tobias Welte
Deutsches Ärzteblatt International 2013, 110 (38): 634-40

BACKGROUND: Nosocomial pneumonia is among the most common types of infection in hospitalized patients. The increasing prevalence of multi-drug resistant organisms (MDROs) in recent years points to the need for an up-to-date clinical guideline.

METHODS: An interdisciplinary S3 guideline was created on the basis of a systematic literature review in the PubMed and Cochrane Library databases, with assessment and grading of the evidence according to the GRADE system.

RESULTS: 9097 abstracts and 808 articles were screened in full text, and 22 recommendations were issued. It is recommended that any antimicrobial treatment should be preceded by a microbiological diagnostic evaluation with cultures of blood and respiratory samples. The diagnosis of nosocomial pneumonia should be suspected in any patient with a new or worsened pulmonary infiltrate who meets any two of the following three criteria: leucocyte count above 10,000 or below 4000/µL, temperature above 38.3°C, and/or the presence of purulent respiratory secretions. The initially calculated antimicrobial treatment should be begun without delay; it should be oriented to the locally prevailing resistance pattern, and its intensity should be a function of the risk of infection with MDROs. The initial treatment should be combination therapy if there is a high risk of MDRO infection and/or if the patient is in septic shock. In the new guideline, emphasis is laid on a strict de-escalation concept. In particular, antimicrobial treatment usually should not be continued for longer than eight days.

CONCLUSION: The new guideline's recommendations are intended to encourage rational use of antibiotics, so that antimicrobial treatment will be highly effective while the unnecessary selection of multi-drug-resistant organisms will be avoided.

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