Monitoring

By definition, patients with HAP are monitored in the hospital. A trend toward improvement is expected within 72 hours of initiating antimicrobial treatment. Typically, a complete blood count, chest x-ray, and oxygenation assessment are carried out daily while patients are in the intensive care unit. If the patient is on a hospital floor, these assessments should be obtained 3 days after diagnosis to verify the diagnosis and subsequent need for antimicrobials. Other affected organ systems should improve as well, as evidenced by higher blood pressure with a decreased need for cardiopressor agents, increased urine output, and more alert mental status. Improvement is an appropriate opportunity to de-escalate antibiotics.

It is not unusual for a patient to have persistent infiltrates on a chest x-ray, as these may take weeks to resolve, but if patients are responding appropriately, then oxygenation requirements should be decreasing.

If improvement is not seen as expected, changing the antibiotic regimen to cover resistant or unusual (e.g., fungal) pathogens should be considered. However, it is also important to evaluate the patient for other pulmonary entities, such as reconsidering whether an effusion may be an exudate (e.g., empyema) instead of a transudate. It is also important to evaluate for other, nonpulmonary sources of infection. A certain procedure may be indicated that was not considered previously, such as an ultrasound of an extremity with an intravenous line in order to rule out septic thrombophlebitis. A bronchoscopy or a thoracentesis may need to be performed for biopsy. Overall, failure of treatment may be due to:[110]

  • A complication

  • A wrong diagnosis

  • Treatment of the wrong pathogen.

Strategies such as changing ventilator settings to pressure support or using an oscillator mode may be considered by a pulmonologist.

If HAP is part of a cascading set of events contributing to multiorgan system failure, then increased morbidity and even death may ensue. In patients who improve and are discharged, a return visit to the clinic is indicated after admission to the hospital. Tests, including imaging, are warranted only if there is a clinical indication, such as fever. Procalcitonin may be checked to guide duration of antimicrobials.

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