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Listen closely to detect healthcare-associated pneumonia

Dobbin, Kathleen MS, RN, ACNP-CS; Howard, Valerie EdD, MS, RN

doi: 10.1097/01.NURSE.0000398834.67045.90

Acquired in healthcare settings, this new category of pneumonia is more complicated and potentially more deadly than community-acquired pneumonia. Here's how to recognize and manage this emerging threat.

Kathleen Dobbin is a nurse practitioner at the W.G. Hefner VA Medical Center in Salisbury, N.C., and Valerie Howard is an associate professor of nursing at Robert Morris University in Pittsburgh, Pa.

THE SHIFT of intensive treatments and patient care to outpatient areas has created a category of respiratory infections in ambulatory patients that can resemble more serious hospital-acquired infections. Called healthcare-associated pneumonia (HCAP), it's associated with a more complicated course, longer hospital stay, and higher mortality than pneumonia acquired in the community.

Nurses must recognize patients with pneumonia who may have acquired the infection through recent healthcare contact outside of hospitalization. Without a detailed health history and physical assessment, the patient's signs and symptoms may be presumed to indicate a community-acquired infection, leading to inadequate treatment and a poor outcome.

This article describes how to take a careful history to recognize HCAP and care for a patient who has this condition.

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Take a closer look at HCAP

Pneumonia is the seventh leading cause of death in America. Studies indicate that HCAP may account for almost one third of CAP, and this number may not be accurate because many patients' recent healthcare contact may not be recognized.1 Since 2005, the designation of HCAP has been used to differentiate patients from those with:

  • hospital-acquired pneumonia (HAP)
  • ventilator-acquired pneumonia (VAP)
  • community-acquired pneumonia (CAP).

For details, see Classifying pneumonia.

Patients developing HCAP tend to be older adults with chronic diseases. They're also more likely to have multidrug resistant (MDR) pathogens and be at a higher risk of death from infection.2

Acquired during recent contact with the healthcare system, HCAP may resemble HAP more closely than CAP. Identifying HCAP early is imperative because inappropriate antibiotic coverage can worsen this dangerous infection and increase mortality.1

In 2005, the American Thoracic Society and the Infectious Disease Society of America published joint guidelines for the identification and management of adults with HAP, VAP, and HCAP.3 These guidelines identify those patients at risk for HCAP, provide diagnostic criteria, and outline recommended therapies. In general, these guidelines suggest that pneumonias identified as HCAP may warrant aggressive therapy that's similar to treatment for a hospital-acquired infection.

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Pathway to infection

Causative pathogens associated with HCAP include Gram-positive and Gram-negative bacilli. The predominant bacterial pathogen causing HCAP is one of two subtypes of Staphylococcus aureus: methicillin-susceptible S. aureus (MSSA) or methicillin-resistant S. aureus (MRSA). MRSA, which accounts for more than 50% of intensive care infections caused by S. aureus, was more prevalent in patients with HCAP in the largest study to date differentiating among patients with CAP, HCAP, HAP, and VAP. Gram-negative pathogens such as Pseudomonas species were responsible for over a quarter of HCAP infections in the same study, which involved over 4,500 patients.3

When host defenses are overwhelmed by exposure to many highly virulent microorganisms entering the lower respiratory tract, infection ensues. Microorganisms typically gain access to the lower respiratory tract through microaspiration from the oropharyngeal tract colonized with the infecting organisms. Septicemia can also lead to pulmonary infection.

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After the microorganism infiltrates the lower respiratory tract, an inflammatory response is mounted that impedes gas exchange at the terminal bronchioles and alveoli. Mucosal edema and increased secretions triggered by the inflammatory response impede air flow and gas exchange.4

Bronchopneumonia describes a more diffuse pattern of infection originating in the bronchi that leads to inflammation of surrounding lung parenchyma. Lobar pneumonia occurs when a substantial area of a lung lobe or multiple lobes are involved.4

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Recognizing HCAP

An accurate health history that identifies risk factors for HCAP is the most important clue that a patient with signs and symptoms of pneumonia could have HCAP. Review the patient's health history, looking for antimicrobial therapy in the preceding 90 days, hospitalizations for 2 or more days in the preceding 90 days that include same-day admissions, and ED visits. Also ask about home care involving wound care or infusion therapies. Patients who receive hemodialysis in a clinic setting are also at risk for HCAP.

Ask the patient about any contact with a friend or family member with an MDR infection such as MRSA. Examine the patient's problem list for chronic diseases such as heart failure, chronic obstructive pulmonary disease, or diabetes because these disorders increase the risk for HCAP. Residing in a long-term-care facility is another red flag.3 For a case study, see Uncovering HCAP.

Clinical findings in HCAP are similar to those found in other types of pneumonias: fever, purulent sputum, cough, dyspnea, or chest or pleuritic pain aggravated by coughing. The pulmonary assessment reveals coarse crackles throughout all lung fields and use of accessory muscles of respiration.5

Additional physical findings over the involved area include:

  • bronchial or bronchovesicular breath sounds
  • bronchophony, egophony, and whispered pectoriloquy
  • increased tactile fremitus
  • dull percussion note
  • late inspiratory crackles.6

Chest X-rays are performed to determine the presence and extent of pulmonary infiltrates.

Lab studies include complete blood cell count with blood and sputum cultures to determine the causative microorganisms.5 To collect a sputum sample, instruct the patient to:

  • rinse the mouth with water to reduce contamination by oral microbes
  • breathe deeply several times
  • cough deeply
  • expectorate the raised sputum into a sterile container.4

As prescribed, obtain arterial blood gases if the patient's oxygen requirements are greater than 4 L/minute to maintain oxygen saturations above 90%.4

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Your role

Managing HCAP appropriately depends on the accurate diagnosis of the causative organism. If cultures are ordered, obtain them before antibiotic therapy is initiated if possible. Empiric antibiotic therapy is indicated in the presence of a new or progressive lung infiltrate with at least two of these three signs:

  • temperature greater than 38°C
  • leukocytosis or leukopenia
  • the presence of purulent secretions.2

The healthcare provider selects initial antimicrobial therapy based on risk factors for specific pathogens (for example, exposure to someone with MRSA), local patterns of antibiotic resistance, and organism prevalence.

You play a pivotal role in monitoring and documenting your patient's response to antibiotic therapy, which will be adjusted if the patient doesn't respond in the first 48 to 72 hours. Once culture and sensitivity studies are completed in 2 to 3 days, antibiotic therapy can be refined to target the causative pathogen.

Nursing considerations for a patient with HCAP include maintaining airway patency and optimizing gas exchange, promoting energy conservation, and maintaining nutrition.4 To ensure airway patency and maximize gas exchange, respiratory secretions must be liquefied and removed. Oxygen delivery with a warmed, high-humidity face mask will help to thin secretions, promoting full expectoration. As prescribed, promote adequate hydration with 2 to 3 L of fluid each day while you monitor fluid and electrolyte balance.5

Teach the patient that coughing and deep breathing are essential for removing secretions. Place your hands on the lower rib cage to help the patient focus on taking slow deep breaths, then apply pressure during the expiratory phase.4 Monitor oxygen saturation during all interventions and titrate oxygen according to prescribed protocols as you assess the patient's response to therapy.

To conserve energy, encourage the patient to take adequate rest periods and avoid overexertion, which can exacerbate signs and symptoms. Place the patient in semi-Fowler position and encourage frequent position changes to increase secretion clearance.4

Many patients with HCAP experience anorexia, which can make adequate nutrition and fluid intake a challenge. Offer drinks with electrolytes and calories and nutritionally enriched shakes as needed.4 If I.V. fluids are required to maintain fluid balance, monitor intake and output carefully, especially in debilitated patients.

Because a patient with HCAP may be on multiple antibiotics, monitor for adverse reactions such as allergic reactions and gastrointestinal effects, including diarrhea, nausea, and anorexia.

If the patient experiences any pruritus, urticaria, or circumoral edema, stop the antibiotic infusion, remain with the patient while constantly assessing and supporting the ABCs, and immediately notify the healthcare provider. Monitor the patient's response to gastrointestinal adverse reactions, such as diarrhea, which can range from moderate to severe. If the patient becomes dehydrated or nutritionally depleted, contact the healthcare provider.

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Avoiding problems

During your patient's treatment, be diligent to detect serious complications of HCAP or therapy, including:

  • anaphylaxis
  • atelectasis
  • pleural effusion
  • superinfections
  • respiratory failure
  • shock.4

Being alert for hypersensitivity reactions and subtle changes in the patient's vital signs can help you identify the beginning stages of shock. Intervening quickly can prevent further compromise.

Perform frequent respiratory assessments, including oxygen saturation and breath sounds, to help identify atelectasis and pleural effusion. Subtle changes in breath sounds warrant more aggressive pulmonary toileting procedures such as coughing, deep breathing, and incentive spirometry. Notify the healthcare provider, who may repeat the chest X-ray.

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Patient teaching

A patient with HCAP and his or her caregivers may falsely believe that this pneumonia is less serious than HAP. Emphasize that the patient needs to complete the prescribed antibiotic therapy even if he or she feels much better. Stress the importance of follow-up care. Chest X-rays are typically obtained to monitor resolution of the pulmonary infiltrate once the patient completes the antibiotic course. Make sure that the patient understands that worsening cough, increased sputum production, and shortness of breath aren't expected; if they occur, the patient should contact the healthcare provider or return to the ED for further evaluation.

Review the importance of annual influenza vaccination and appropriate pneumococcal vaccination with the patient and family. If hospitalized, your patient should receive these vaccinations before discharge, if appropriate.

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Preventing HCAP

In 2003, the CDC and the Healthcare Infection Control Practices Advisory Committee established guidelines to reduce the incidence of pneumonia in acute care hospitals and other healthcare settings. The recommendations for preventing healthcare-associated bacterial pneumonia are extensive and highly detailed, but the guidelines can be broken down into staff activities that may lower infection rates and primary preventive measures. These guidelines provide prevention practices that nurses in any environment can follow to lower the risk of bacterial transmissions that lead to HCAP.7

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Ms. G, 76, presents to the ED complaining of a 3-day history of shortness of breath, productive cough, pleuritic chest pain, and fever. She has a history of heart failure and type 2 diabetes and resides in a skilled nursing facility.

Her temperature is 38.5° C (101.3° F), pulse 110, respiratory rate 28, SpO2 89% on room air, and BP 156/92. A chest X-ray reveals a new lung infiltrate and small bilateral pleural effusions. The triage nurse also notes that Ms. G was treated with antibiotics in the last month for a left lower extremity cellulitis.

Before 2005, this patient would have been diagnosed with CAP shortly after her arrival in the ED, based on her signs and symptoms and the presence of a new infiltrate on chest X-ray. More than likely, she'd have been treated with a single antibiotic appropriate for CAP.

Under current guidelines, however, she's recognized as at risk for HCAP because she resides in a skilled nursing facility, has two chronic illnesses, and recently received antibiotics. A causative MDR pathogen is much more likely in this scenario. Initial treatment will include more than one antibiotic for broad MDR coverage until the causative organism is identified through sputum or blood cultures.2

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1. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388–416.
2. Venditti M, Falcone M, Corrao S, Licata G, Serra P; Study Group of the Italian Society of Internal Medicine. Outcomes of patients hospitalized with community-acquired, health care-associated, and hospital-acquired pneumonia. Ann Intern Med. 2009;150(1):19–26.
3. Kollef MH, Shorr A, Tabak YP, Gupta V, Liu LZ, Johannes RS. Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest. 2005;128(6):3854–3862.
4. Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner and Suddarth's Textbook of Medical-Surgical Nursing. 12th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2008.
5. Lewis SL, Heitkemper MM, Dirksen SR, O'Brien PG, Bucher L, eds. Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 7th ed. St. Louis, MO: Elsevier Mosby; 2007.
6. Bickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2009.
7. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R; Centers for Disease Control and Prevention; Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care–associated pneumonia. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53(RR-3):1–36.
8. Kollef MH, Shorr A, Tabak YP, Gupta V, Liu LZ, Johannes RS. Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest. 2005;128(6):3854–3862.
© 2011 Lippincott Williams & Wilkins, Inc.