Nosocomial pneumonia

Case report:

A 28 year old patient was admitted after a motorcycle accident in the intensive care unit and must be immediately intubated and ventilated due to severe chest injuries and respiratory insufficiency. On the fourth day after admission, the patient developed fever, purulent tracheal secretion and an increased radiological infiltration in the right lower lobe. About this area can auscultate pneumonic sounds that hitherto simple ventilation is degraded by an increased oxygen demand and increased inspiratory pressure values.

Diagnosis:

The findings described and the additional charges inflammation parameters with a leukocytosis of 22,000 / ul and a marked left shift in differential blood count and an elevated CRP above 80 mg / l indicate a ventilator-associated pneumonia. The immediately carried out bronchoscopy with quantitative analysis of bronchoalveolar lavage results in the detection of Staphylococcus aureus in a high bacteria count.

Pathogenesis:

The thoracic trauma and the necessary ventilation must be considered as risk factors for the development of pneumonia. Pathogenetically responsible for this are significant disturbances of defense mechanisms such as lifting the Larynxverschlusses, absence of cough, disturbances bronchoalveolar clearance and respiratory mechanics. In a manifestation of pneumonia until the fifth day is a so-called "early pneumonia", which is usually associated with community-acquired pathogens. Here come Pneumococcal, Haemophilus influenzae, staphylococci or streptococci Anaerobic into consideration. The resistance of these pathogens is generally not a problem, since they are not from the hospital environment, but from our own body flora, especially the oropharynx, originate.

Therapy:

The empirical initial therapy of such so-called early nosocomial pneumonia in intensive care units should be carried out by standard antibiotics in the field of cephalosporins and / or the broad-spectrum penicillins. In the present case of disease, the staphylococci showed normal resistance situation and were resistant to clindamycin (SOBELIN) flucloxacillin (STAPHYLEX) Standardcephalosporinen as cefotiam (SPIZEF), cefuroxime (CEFUROXIME etc.) and cefazolin (GRAMAXIN others), but also to amoxicillin plus clavulanic acid (Augmentin) and ampicillin plus sulbactam (UNACID) sensitively. It was initiated with clindamycin at a dose of 600 mg three times IV monotherapy, whereby any existing anaerobes are detected; Alternatives in this situation would be quite amoxicillin plus clavulanic acid or ampicillin plus sulbactam. The duration of treatment at a staphylococcal pneumonia should be eight to 14 days, with the treating physician should be based on the course of development of the inflammation parameters. Of particular importance is certainly the quickest possible weaning the patient from the ventilator and subsequent extubation.