Académique Documents
Professionnel Documents
Culture Documents
Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research1 (PGIMER),
Chandigarh; Indian Chest Society2 and National College of Chest Physicians (India)3, Delhi, India
*
Pneumonia Guidelines Working Group (In alphabetical order)
Pranab Baruwa, Guwahati; R.S. Bedi, Patiala; D. Behera, New Delhi; Ashish Bhalla, Chandigarh; Dhruva Chaudhry, Rohtak;
S.K. Chhabra, Delhi; Vishal Chopra, Patiala; D.J. Christopher, Vellore; George DSouza, Bengaluru; D. Dadhwal, Chandigarh;
Sahajal Dhooria, Chandigarh; Mandeep Garg, Chandigarh; Vikas Gautam, Chandigarh; Vishwanath Gella, Chandigarh; Aloke G. Ghoshal,
Kolkata; Bharat Gopal, New Delhi; Abhishek Goyal, Chandigarh; Randeep Guleria, New Delhi; K.B. Gupta, Rohtak; Ajay Handa,
Bengaluru; Jai Kishan, Chandigarh; Sanjay Jain, Chandigarh; Nirmal K. Jain, Jaipur; Vikram K. Jain, Jaipur; A.K. Janmeja, Chandigarh;
Aditya Jindal, Chandigarh; Surya Kant, Lucknow; Surender Kashyap, Karnal; Samir Malhotra, Chandigarh; Dipesh Maskey, Chandigarh;
V. Nagarjun Mataru, Chandigarh; Sabir Mohammed, Bikaner; Rajendra Prasad, Etawah; P. Sarat, Chandigarh; Honey Sawhney, Chandigarh;
Nusrat Shafiq, Chandigarh; Navneet Sharma, Chandigarh; S.K. Sharma, New Delhi; Sunil Sharma, Shimla; U.P.S. Sidhu, Ludhiana;
Inderpal Singh, Chandigarh; Deepak Talwar, Noida; and Subhash Varma, Chandigarh.
[Indian J Chest Dis Allied Sci 2012;54:267-281]
Note: Complete version of these guidelines is published in Lung India 2012;29: S27-S62.
Correspondence and reprint requests: Dr Dheeraj Gupta, Professor, Department of Pulmonary Medicine, Postgraduate
Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh-160 012, India; Phone: 91-172-2756823 (Work);
Fax: 91-172-274215; E-mail: dheeraj1910@gmail.com
268 Pneumonia Guidelines D. Gupta et al
What is the Role of Biomarkers in the 4. For out-patients with comorbidities [Table 5],
Diagnosis of CAP? oral combination therapy is recommended (-
lactams plus macrolides) (1A).
Procalcitonin and C-reactive protein need not be 5. There is insufficient evidence to recommend
performed as routine investigations for the diagnosis tetracyclines (3B).
of CAP (2A).
6. Fluoroquinolones should not be used for
empirical treatment [Table 6] (1A).
Should Patients with CAP be Risk
Stratified? What Should be the Optimum 7. Antibiotics should be given in appropriate doses
to prevent emergence of resistance (1A).
Method of Risk Stratification?
1. Patients with community acquired pneumonia
What Should be the Antibiotic Therapy in
should be risk stratified [Table 2] (1A). the Hospitalised Non-ICU Setting?
2. Risk stratification should be performed in two 1. The recommended regimen is combination of a
steps (Figure 1) based upon the need for hospital -lactam plus a macrolide (preferred beta-
admission followed by the assessment of the site lactams include cefotaxime, ceftriaxone and
of admission (non-intensive care unit (ICU) amoxicillin-clavulanic acid) (1A).
versus ICU). Accordingly, patients can be
managed as either out-patient or in-patient 2. In the uncommon scenario of hypersensitivity to
(ward or ICU) (1A). -lactams, respiratory fluoroquinolones (e.g.,
levofloxacin 750mg daily) may be used if
3. Initial assessment should be done with CRB-65. tuberculosis (TB) is not a diagnostic
If the score is >1, patients should be considered consideration at admission (1A). Patients should
for admission (1A). also undergo sputum testing for AFB
4. Clinical judgement should be applied as a simultaneously if fluoroquinolones are being
decision modifier in all cases (3A). used in place of -lactams.
5. Pulse oximetry can be used to admit hypoxaemic 3. Route of administration (oral or parenteral)
patients (2A). Hypoxaemia is defined as pulse should be decided based upon the clinical
oximetric saturation 92% and 90% for age condition of the patient and the treating
50 and 50 years, respectively (3A). physicians judgement regarding tolerance and
6. Patients selected for admission can be triaged to efficacy of the chosen antibiotics (3A).
the ward (non-ICU/ICU based upon the 4. Switch to oral from intravenous therapy is safe
major/minor criteria outlined in table 2 (2A). after clinical improvement in moderate to severe
7. If any major criterion or 3 minor criteria are CAP (2A).
fulfilled, patients should generally be admitted to What Should be the Antibiotic Therapy in
the ICU (1A). ICU Setting?
What Practices are Recommended Regarding 1. The recommended regimen is a -lactam
Use of Antibiotics in CAP? (cefotaxime, ceftriaxone or amoxicillin-clavulanic
acid) plus a macrolide for patients without risk
Antibiotics should be administered as early as factors for Pseudomonas aeruginosa (2A).
possible; timing is more important in severe CAP (2A). 2. If P. aeruginosa is an aetiological consideration,
an anti-pneumococcal, antibiotic (e.g., cefepime,
What Should be the Antibiotic Therapy in ceftazidime, cefoperazone, piperacillin-
the Out-patient Setting? tazobactam, cefoperazone-sulbactam, imipenem
or meropenem) should be given (2A).
1. Therapy should be targeted towards coverage Combination therapy may be considered with
the most common organisms, namely the addition of aminoglycosides/anti-
Streptococcus pneumoniae [Table 3] (1A). pseudomonal fluoroquinolones (e.g.,
ciprofloxacin) (3A). Fluoroquinolones may be
2. Out-patients should be stratified as those with or used if TB is not a diagnostic consideration at
without comorbidities (3A). admission (1A). Patients should also undergo
3. Recommended antibiotics [Table 4] are oral sputum testing for AFB simultaneously if
macrolides (e.g. azithromycin) or oral -lactams fluoroquinolones are being used.
(e.g., amoxicillin 500-1000 mg thrice daily) for 3. Antimicrobial therapy should be changed
out-patients without comorbidities (1A). according to specific pathogen(s) isolated (2A).
270 Pneumonia Guidelines D. Gupta et al
7. Appropriate management should not be delayed 2. In hospitals that do not have their own antibiotic
in clinically unstable patients for the purpose of policy, the policy given in these guidelines is
performing diagnostic sampling (UPP). recommended (3A). However, they should strive
towards formulating their own antibiotic policy.
Are Quantitative Methods of Culture Better
than Semi-quantitative Methods? What is the Role of Routine ETA culture
Semi-quantitative cultures of lower respiratory tract Surveillance?
secretions are easier and equally discriminatory for Routine ETA culture is not recommended. An
the presence of pneumonia, as compared to antibiogram approach should be followed wherever
quantitative cultures (UPP). feasible (2A).
Are Invasive Techniques to Collect Lower Is There a Benefit of Combination Therapy
Respiratory Tract Secretions Better than Over Monotherapy for the Treatment of
Blind Endotracheal Aspirates? HAP/VAP and HCAP?
1. Quantitative and or semi-quantitative cultures
using various sampling techniques, like Although there is no evidence to suggest that
endotracheal aspirate (ETA), bronchoscopic or combination therapy is superior to monotherapy, the
non-bronchoscopic bronchoalveolar lavage expert group recommended initial empiric therapy as
(BAL) and protected specimen brush (PSB) are a combination due to the high prevalence rates of
equally useful for establishing the diagnosis of MDR pathogens (Figure 2) in late-onset HAP/VAP,
HAP/VAP (2A). [Table 11] and with an aim to ensure the chances of
2. Semi-quantitative culture on blind (non- appropriateness of the initial regimen (UPP).
bronchoscopic) ETA sample (preferably obtained However, once the culture reports are available, the
through a sterile telescoping catheter system) is a regimen should be de-escalated to the appropriate
reasonable choice (2A). monotherapy (1A).
3. In a patient suspected of having VAP, the What is the Recommended Strategy for
preferred method for lower respiratory tract
Initiating Antibiotics in Suspected HAP/VAP?
sample collection (blind or targeted,
bronchoscopic or non-bronchoscopic) depends 1. In patients with suspected HAP, antibiotics
upon individual preferences, local expertise and should be initiated as early as possible after
cost; however, blind ETA sampling is easiest and sending the relevant samples for culture (1A).
equally useful (UPP). 2. The exact choice of antibiotic to be started is
based on local availability, antibiotic resistance
What is the Role of Biomarkers in Diagnosis
patterns, preferred routes of delivery, other
of HAP/VAP? complicating factors and cost.
1. Currently available biomarkers should not be 3. The initial combination therapy should be
used to diagnose HAP/VAP (1A). converted to appropriate monotherapy once
2. Where available, serum procalcitonin levels culture reports are available (1A).
<0.5 ng/mL may help in differentiating bacterial 4. Colistin is not recommended as an initial empiric
HAP/VAP form other non-infective aetiologies, therapy for HAP/VAP (3A).
and may help in decisions for antibiotic 5. Combination therapy with colistin and
cessation (2B). meropenem is not recommended (2A).
Is Combined Clinico-bacteriological Strategy Is Antibiotic De-escalation Useful? What is
Better than Either Strategy Used Alone? the Strategy for Antibiotic De-escalation?
Both clinical and bacteriological strategies can be 1. The strategy for de-escalation of antibiotics is
combined to better diagnose and manage HAP and strongly recommended (1A). However, as the de-
VAP (UPP). escalation strategy entirely rests on microbiology,
How do We Decide on the Empiric Antibiotic appropriate microbiological samples should be
Regimen to be Started in a Case of sent before initiation of antibiotics (Figure 3).
2. Among patients with suspected VAP in whom
Suspected HAP/VAP? an alternate cause for pulmonary infiltrates is
1. Every ICU/hospital should have its own identified, it is recommended that antibiotics
antibiotic policy for initiating empiric antibiotic should be stopped (1A).
therapy in HAP based on their local 3. If cultures are sent after initiation of antibiotics,
microbiologic flora and resistance profiles (1A). and there is clinical improvement with
This policy should be reviewed periodically. subsequent cultures being sterile, antibiotics
272 Pneumonia Guidelines D. Gupta et al
should be continued for seven days followed by or teicoplanin (2A). The use of linezolid in India
the assessment of clinical pulmonary infection should be reserved because of its potential use in
score (CPIS) [Table 12] on the 7 th day. If CPIS is extensively drug-resistant TB.
<6, antibiotics can be stopped while if it is 6, 2. Linezolid is an effective alternative to
treatment should be continued for 10 to 14 days. vancomycin (1A) if the patient is (a) vancomycin
4. If cultures sent before starting antibiotics are intolerant; (b) has renal failure; and (c)
negative and there is clinical worsening, it is harbouring vancomycin resistant organism.
recommended that a review of the current
How to Treat MDR Acinetobacter infections?
management plan including the choice of
antibiotics be performed. Microbiological work- 1. For the treatment of MDR Acinetobacter infections,
up should be repeated including performance of we recommend the following drugs:
fungal cultures. One also needs to look for carbapenems (1A), colistin (1A), sulbactam plus
alternate sources of sepsis (especially one or colistin (2B), sulbactam plus carbapenem (2B)
more focus of undrained infection), and consider and polymyxin B (2A).
non-infective causes. 2. Combination therapy with sulbactam and
5. Empiric antifungal therapy (at day 3) should not colistin or carbapenem for MDR Acinetobacter (in
be used as a routine in all patients, if cultures are proven cases or suspected cases with multi-
sterile and there is clinical worsening (3A). organ dysfunction syndrome [MODS]) may be
initiated. Sulbactam should be stopped after five
What is the Optimal Duration of Antibiotic days in patients responding to treatment (2B).
Therapy?
How to treat MDR Pseudomonas Infections?
1. In patients with VAP due to Pseudomonas,
Acinetobacter and methicillin-resistant For the treatment of MDR Pseudomonas, we
Staphylococcus aureus (MRSA), a longer duration (14 recommend initial combination chemotherapy with a
days) of antibiotic course is recommended (1A). carbapenem and either a fluoroquinolone or
Assessment of CPIS at day 7 may identify patients aminoglycoside (1A). Treatment should then be de-
in whom therapy could be stopped early (2A). escalated to appropriate monotherapy.
2. In other patients with VAP who are clinically What are the Other Good Practices to be
improving, a 7-day course of antibiotics is
recommended (1A).
Followed in the ICU?
1. Stress ulcer prophylaxis: Sucralfate should be used
Is Continuous Infusion of Antibiotics Better
in patients with HAP while H-2 receptor
than Intermittent Doses? antagonists or proton pump inhibitors should be
Antibiotic administration in critically ill patients used in patients with VAP.
according to their pharmacokinetic/pharma- 2. Early enteral feeding: Enteral feeding is superior to
codynamic profile [Table 13] is recommended as it is parenteral nutrition and should be used
associated with superior clinical outcomes (2A). whenever tolerated and in those without any
contraindications to enteral feeding.
What is the Role of Inhaled Antibiotics in 3. Deep venous thrombosis (DVT) prophylaxis: DVT
the Treatment of VAP? prophylaxis with unfractionated heparin (5000
1. Aerosolised antibiotics (colistin and tobramycin) U thrice a day) or a low molecular weight
may be a useful adjunct to intravenous heparin should be routinely used in all ICU
antibiotics in the treatment of MDR pathogens patients with no contraindications to
where toxicity is a concern (2A). prophylactic anticoagulation.
2. Aerosolised antibiotics should not be used as 4. Glucose control: A plasma glucose target of 140-
monotherapy and should be used concomitantly 180 mg/dL is recommended in most patients
with intravenous antibiotics (2A). with HAP/VAP, rather than a more stringent
target (80-110 mg/dL) or a more liberal target
Should one Treat Ventilator Associated (180 -200 mg/dL).
Tracheobronchitis (VAT)? 5. Blood products: Red cells should be transfused at a
haemoglobin threshold of <7 gm/dL except in
Patients with proven VAT should not be treated with those with myocardial ischaemia and pregnancy.
antibiotics (2A). Platelet transfusion is indicated in patients with
What are the Drugs of Choice for Treatment platelet count <10000/L, or <20000/L if there
is active bleeding. Fresh frozen plasma is
of MRSA?
indicated only if there is a documented
1. In patients with suspected MRSA infection, we abnormality in the coagulation tests and there is
recommend the use of empiric vancomycin (1A) active bleeding or if a procedure is planned.
2012;Vol.54 The Indian Journal of Chest Diseases & Allied Sciences 273
Table 1. Classification of level of evidence and grading of recommendation based on the quality of evidence supporting the
recommendation
Classification of Level of Evidence
Level 1 High quality evidence backed by consistent results from well performed randomised controlled trials, or overwhelming
evidence from well-executed observational studies with strong effects
Level 2 Moderate quality evidence from randomised trials (that suffer from flaws in conduct, inconsistency, indirectness,
imprecise estimates, reporting bias, or other limitations)
Level 3 Low-quality evidence from observational evidence or from controlled trials with several serious limitations
Useful Not backed by sufficient evidence, however a consensus reached by working group, based on clinical experience and
Practice Point expertise
Grading of Recommendation Based on the Quality of Evidence
Grade A Strong recommendation to do (or not do) where the benefits clearly outweigh the risk (or vice versa) for most, if not all
patients
Grade B Weaker recommendation where benefits and risk are more closely balanced or are more certain
Table 2. Summary of commonly used criteria for risk stratification in community acquired pneumonia
CURB-65 CRB-65 SMART-COP SMRT-CO ATS-IDSA Criteria
Confusion Confusion Low systolic blood pressure Low systolic blood Major criteria
(<90 mmHg) pressure (<90 mmHg)
Urea 7 mmol/L Respiratory rate 30/min (a) Invasive mechanical
Multilobar CXR involvement Multilobar CXR involvement ventilation
Respiratory rate 30/min Low blood pressure
(diastolic blood pressure Low albumin (<3.5 g/dL) Respiratory rate (25/min) (b) Septic shock with the need
Low blood pressure
60 mmHg or systolic blood for vasopressors
(diastolic blood pressure Respiratory rate (25/min) Tachycardia (125/min)
pressure 90 mmHg)
60mmHg or systolic Minor criteria
Tachycardia (125/min) Confusion
blood pressure 90mmHg) Age 65 years
(a) Respiratory rate 30
Confusion Poor oxygenation
Age 65 years breaths/min
(PaO2 <70 mm Hg; SpO2 < 93%)
Poor oxygenation
(b) PaO2/FIO2 ratio 250
(PaO2 <70mmHg; SpO2 <93%)
(c) Multilobar infiltrates
Low pH (<7.35)
(d) Confusion/disorientation
(e) Uraemia (BUN level 20
mg/dL)
(f) Leukopaenia (WBC count
<4000 cells/mm3)
(g) Thrombocytopaenia
(platelet count <100,000
cells/mm3)
(h) Hypothaermia (core
temperature <36 C)
CURB-65=Confusion, urea, respiratory rate, blood pressure-65; CRB-65=Confusion, respiratory rate, blood pressure-65; ATS-IDSA=American Thoracic Society
Infectious Disease Society of America; BUN=Blood urea nitrogen; CXR=Chest radiograph; PaO2=Partial pressure of oxygen in arterial blood; SpO2=Arterial oxygen
saturation; FIO2=Fraction of oxygen in inspired air; WBC=White blood cell
Table 3. Summary of studies on choice of antibiotics for treatment of community acquired pneumonia (CAP)
Author(s)ref. Year Type of Study Conclusions
Mills et al2 2005 Meta-analysis 18 trials totalling 6749 in non-severe all cause CAP; compared beta-
lactams versus atypical cover; clinical outcomes not improved with
atypical cover
Shefet et al3 2005 Cochrane meta-analysis 24 trials including 5015 randomised patients; no benefit of atypical
cover (fluoroquinolone monotherapy versus non-atypical
monotherapy)
Metersky et al4 2007 Retrospective analysis 2209 patients with bacteremic pneumonia; initial antibiotic
treatment including a macrolide agent was associated with
improved outcomes
Reyes Calzada et al 5 2007 Prospective multicentre study 425 hospitalised patients; beta-lactam monotherapy associated
with increased risk of re-admission
Iannini et al6 2007 Retrospective, multicentre study 87 of 122 patients showed low level erythromycin resistance
Tamm et al 7
2007 Prospective, randomised, Compared ceftriaxone plus either azithromycin or clarithromycin or
multicentre study erythromycin for moderate-severe CAP; equivalence noted
Cont...
274 Pneumonia Guidelines D. Gupta et al
Table 3 Cont...
Dartois et al8 2008 Randomised, double-blind, Compared tigecycline with levofloxacin for CAP PSI 2 4;
phase 3 multinational trial tigecycline was safe and of similar efficacy to levofloxacin
Lloyd et al9 2008 Randomised control trial Compared moxifloxacin versus levofloxacin + ceftriaxone in 738
patients requiring hospitalisation; no difference in efficacy;
moxifloxacin cheaper
Maipmon et al10 2008 Meta-analysis No advantage of atypical coverage in mild-moderate outpatient CAP
Paris et al11 2008 Randomised, open-label, Compared azithromycin 1g once daily x 3 days to amoxicillin-
non-inferiority study clavulanic acid 875/125 mg twice daily x 7 days; no difference in
safety and efficacy
Pertel et al12 2008 Two phase-3 randomised, Daptomycin was not effective for the treatment of CAP, including
double-blind trials infections caused by Streptococcus pneumoniae and Staphylococcus
aureus
Ye et al13 2008 Retrospective analysis of 2968 patients treated with levofloxacin and 4558 with a macrolide;
claims data rates of treatment failure less with levofloxacin; overall CAP-related
hospitalisations and costs did not differ significantly
Bergallo et al14 2009 Double-blind, randomised, Tigecycline was safe, effective, and non-inferior to levofloxacin in
phase 3 comparison study hospitalised patients with CAP
Bjerre et al15 2009 Cochrane meta-analysis Six randomised controlled trials assessing five antibiotic pairs with
1857 patients; evidence insufficient to make evidence-based
recommendations for the choice of antibiotic; individual study
results do not reveal significant differences in efficacy between
various antibiotics and antibiotic groups
Liu et al16 2009 Prospective study 610 patients; non-susceptibility of Streptococcus pneumoniae to
penicillin and azithromycin was 22.2% and 79.4%, respectively
Lui et al17 2009 Prospective, observational 1193 patients; 28% of CAP caused by atypical organisms; disease
study severities and outcomes similar to patients with CAP due to other
organisms
Tanaseanu et al18 2009 Prospective, double-blind, IV tigecycline was non-inferior to IV levofloxacin and was well-
non-inferiority phase 3, tolerated
randomised control trial
Tessmer et al19 2009 Observational study of 1854 patients; compared beta-lactam monotherapy to beta-
German competence lactam/macrolide combination; beta-lactam/macrolide therapy
network CAPNETZ with CRB-65 risk classes of 2 or higher was superior in respect to 14
day mortality and was also associated with lower risk of treatment
failure
von Baum et al20 2009 Prospective analyses from 307 of 4532 patients had Mycoplasma pneumonia; relatively benign
CAPNETZ presentation; atypical coverage need to be re-considered
An et al21 2009 Meta-analysis Seven randomised controlled trials involving 3903 patients;
moxifloxacin monotherapy was associated with similar clinical
treatment success rates and similar mortality to beta-lactams
File et al22 2010 Two randomised, double-blind, 614 patients each in ceftaroline and ceftriaxone group for PSI 3 4
multicentre trials (non-ICU); ceftaroline was non-inferior to ceftriaxone in the
individual trials while clinical cure rates were numerically higher in
integrated analysis
Hess et al23 2010 Retrospective cohort study 3994 patients; treatment failure less likely with quinolones than
azithromycin, an effect particularly marked in high-risk patients
Cai et al24 2011 Meta-analysis Eight randomised controlled trials involving 4651 patients;
compared with empirical antibiotic regimens, tigecycline
monotherapy was associated with similar clinical treatment success
rates, higher adverse effects and similar all-cause and drug-related
mortality
Ewig et al25 2011 Retrospective cohort study 4091 patients; 2068 patients received moxifloxacin and 1703 lactam
monotherapy; moxifloxacin monotherapy had higher survival as
compared to lactam monotherapy in CRB-65 = 1 or 2
PSI=Pneumonia severity index; IV=Intravenous; CRB-65=Confusion, respirartory rate, blood pressure-65; ICU=Intensive care unit;
CAPNETZ=German Competence Network for Community-Acquired Pneumonia
2012;Vol.54 The Indian Journal of Chest Diseases & Allied Sciences 275
Table 4. Doses of drugs used in community acquired Table 7. High risk groups in whom vaccination is
pneumonia recommended
Drug Doses Pneumococcal Disease
Amoxicillin 0.5-1 g thrice daily (PO or IV) Chronic cardiovascular, pulmonary, renal, or liver disease
Co-amoxiclav 625 mg thrice a day to 1 g twice Diabetes mellitus
daily (PO) / 1.2 g thrice daily (IV)
Cerebrospinal fluid leaks
Azithromycin 500 mg daily (PO or IV)
Alcoholism
Ceftriaxone 1-2 g twice daily (IV)
Asplenia
Cefotaxime 1 g thrice daily (IV)
Immunocompromising conditions/medications
Cefepime 1-2 g two to three times a day (IV) Influenza
Ceftazidime 2 g thrice daily (IV) Chronic cardiovascular or pulmonary disease (including
Piperacillin-tazobactam 4.5 g four times a day (IV) asthma)
Imipenem 0.5-1 g three to four times a day (IV) Chronic metabolic disease (including diabetes mellitus)
Table 9. Studies reporting the incidence of HAP/VAP from the Indian subcontinent
Studyref. Year Type of Study Duration Diagnostic Criteria Type of Patient CFU/mL No. of Incidence of Mortality
(Years) Patients VAP (%) (%)
Mukhopadhyay et al31 2003 Prospective 1 Clinical, PSB, BAL Surgical ICU 105 241 53.9 47.3
Singhal et al 33 2005 Retrospective 1 Non bronchoscopic BAL ICU 104 478 35.77
Joseph et al36 2009 Prospective 1.5 Clinical, ETA Medical ICU 105 1248 16
Table 10. Modified Centers for Disease Control and Prevention (CDC) criteria for diagnosis of HAP/VAP
Chest radiographic opacities (new, progressive or persistent infiltrate or cavitation) AND
At least two of the following:
1. Fever >38 C or >100.4 F
2. Leukopaenia (<4000 WBC/L) or leukocytosis ( 12000 WBC/L)
3. Altered mental status with no other recognised cause in the elderly
4. New onset of purulent sputum, or change in character of sputum, or increased respiratory secretions, or increased
suctioning requirements
5. Worsening gas exchange (e.g., desaturations, increased oxygen requirements, or increased ventilator demand)
6. New onset or worsening cough, or dyspnoea, or tachypnoea
7. Rales or bronchial breath sounds
Adapted from: Reference38
HAP=Hospital-acquired pneumonia; VAP=Ventilator associated pneumonia; WBC=White blood cell
30 Guidelines for the management of adults with hospital- 35 Prakash S, Rai A, Gogia AR, Prakash S. Nosocomial
acquired, ventilator-associated, and healthcare-associated pneumonia in mechanically ventilated patients receiving
pneumonia. Am J Respir Crit Care Med 2005;171:388-416. ranitidine or sucralfate as stress ulcer prophylaxis. Indian
31 Mukhopadhyay C, Bhargava A, Ayyagari A. Role of J Anesth 2008;52:179-84.
mechanical ventilation and development of multidrug 36 Joseph NM, Sistla S, Dutta TK, Badhe AS, Rasitha D,
resistant organisms in hospital acquired pneumonia. Parija SC. Ventilator-associated pneumonia in a tertiary
Indian J Med Res 2003;118:229-35. care hospital in India: role of multi-drug resistant
32 Rakshit P, Nagar VS, Deshpande AK. Incidence, clinical pathogens. J Infect Dev Ctries 2010;4:218-25.
outcome,and risk stratification of ventilator associated 37 Bajpai S, Karnad DR. De-escalation of antibiotics in
pneumonia- a prospective cohort study. Indian J Crit Care nosocomial pneumonia in an Indian intensive care unit.
Med 2005;9:211-6. Int J Med Med Sci 2010;2:148-52.
33 Singhal R, Mohanty S, Sood S, Das B, Kapil A. Profile of 38 Horan TC, Andrus M, Dudeck MA. CDC/NHSN
bacterial isolates from patients with ventilator associated surveillance definition of health care-associated infection
pneumonias in a tertiary care hospital in India. Indian J and criteria for specific types of infections in the acute
Med Res 2005;121:63-4. care setting. Am J Infect Control 2008;36:309-32.
34 Agarwal R, Gupta D, Ray P, Aggarwal AN, Jindal SK. 39 Fartoukh M, Maitre B, Honore S, Cerf C, Zahar JR, Brun-
Epidemiology, risk factors and outcome of nosocomial Buisson C. Diagnosing pneumonia during mechanical
infections in a respiratory intensive care unit in North ventilation: the clinical pulmonary infection score
India. J Infect 2006;53:98-105. revisited. Am J Respir Crit Care Med 2003;168:173-9.