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576 PART 5: Infectious Disorders

care for our sepsis patients. The debate about colloids and crystalloids CHAPTER Pneumonia
continues particularly for patients with sepsis, with near completion
of the EARSS trial comparing albumin to crystalloid in early septic Richard G. Wunderink
shock. New therapies are being tested, including new monoclonal and 65
polyclonal antibodies, talactoferrin, resveratrol, growth factors, and Grant Waterer
vasopressin agonists. Perhaps like most fields, the most intriguing areas
in sepsis are with cell-based therapies, such as stem cells and other pro-
genitor cell types. Regardless of breakthroughs in disease understanding KEY POINTS
or new therapies, our best hope for improving survival of patients with
sepsis is early recognition and timely delivery of the best care. This • Pneumonia is one of the most common causes of ICU admission,
requires a deliberate effort from a collaborative team, as promulgated usually because of impending respiratory failure or hemodynamic
by the Surviving Sepsis Campaign, and has the best potential for saving compromise.
lives today. • Pneumonia on admission to the intensive care unit presents in
three different forms: traditional community-acquired pneumonia
(CAP), hospital-acquired pneumonia (HAP), and the controver-
KEY REFERENCES sial entity of health care–associated pneumonia (HCAP).

• American College of Chest Physicians/Society of Critical Care • By far, the most important risk factor for oropharyngeal coloniza-
Medicine Consensus Conference: definitions for sepsis and organ tion with pathogenic bacteria is the use of antibiotics; the broader
failure and guidelines for the use of innovative therapies in sepsis. the antibiotic spectrum and the longer the duration of treatment, the
Crit Care Med. 1992;20(6):864-874. more likely that pathogenic bacteria will colonize the oropharynx.
• Caironi P, Tognoni G, Masson S, et al. Albumin replacement • Despite concern about secretion clearance, intermittent noninva-
in patients with severe sepsis or septic shock. N Engl J Med. sive ventilation (NIV) with careful attention to increasing secretion
2014;370:1412-1421. clearance has a survival benefit in CAP and immunocompromised
• Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis patients with pulmonary infiltrates.
Campaign: international guidelines for management of severe • CAP is the leading cause of infectious death around the world and
sepsis and septic shock: 2008. Crit Care Med. 2008;36(1): a frequent cause of ICU admission.
296-327. • While Streptococcus pneumoniae remains the most common cause
• Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, of severe CAP, other pathogens are overrepresented in patients
Kline JA. Lactate clearance vs central venous oxygen saturation as admitted to the ICU, including Staphylococcus aureus, Legionella,
goals of early sepsis therapy: a randomized clinical trial. JAMA. Pseudomonas, and other gram negatives.
2010;303(8):739-746. • Because of the broader spectrum of etiologies, an aggressive diagnos-
• Kumar A, Roberts D, Wood KE, et al. Duration of hypotension tic approach is appropriate in patients admitted to the ICU with CAP.
before initiation of effective antimicrobial therapy is the critical Blood cultures and tracheal aspirate/bronchoalveolar lavage samples
determinant of survival in human septic shock. Crit Care Med. through the endotracheal tube are much more likely to be positive than in
2006;34(6):1589-1596. non-ICU patients.
• Lacy P. Metabolomics of sepsis-induced acute lung injury: a new • Patients initially admitted to a non-ICU setting but subsequently
approach for biomarkers. Am J Physiol Lung Cell Mol Physiol. requiring ICU transfer have high mortality that exceeds that of
2011;300(1):L1-L3. patients with equivalent illness at presentation who are admitted
• Landry DW, Levin HR, Gallant EM, et al. Vasopressin defi- directly to the ICU. Presence of at least three of a set of minor criteria
for severity identifies patients likely needing ICU care and the prob-
ciency contributes to the vasodilation of septic shock. Circulation. ability increases with an increasing number of these minor criteria.
1997;95(5):1122-1125.
• Nobre V, Harbarth S, Graf JD, Rohner P, Pugin J. Use of procalci- • The HCAP designation was developed in response to the consis-
tent finding of pneumonia acquired while outside the hospital but
tonin to shorten antibiotic treatment duration in septic patients: caused by pathogens traditionally associated with HAP, such as
a randomized trial. Am J Respir Crit Care Med. 2008;177(5): MRSA, Pseudomonas, and drug-resistant Enterobacteriaceae. The
498-505. definition remains very controversial.
• ProCESS Investigators, Yealy DM, Kellum JA, et al. A randomized • HAP precipitating respiratory failure and ICU transfer is now more
trial of protocol-based care for early septic shock. N Engl J Med. common than VAP complicating respiratory failure, although both
2014;370:1683-1693. are caused by similar multidrug-resistant (MDR) pathogens.
• Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy • At least one potential pathogen is isolated in up to 75% of patients
in the treatment of severe sepsis and septic shock. N Engl J Med. with HAP who are intubated. Access to the lower respiratory tract
2001;345(19):1368-1377. via the endotracheal tube is the most important reason for the
• Russell JA, Walley KR, Singer J, et al. Vasopressin versus norepi- higher diagnostic yield.
nephrine infusion in patients with septic shock. N Engl J Med. • Broad-spectrum β-lactam antibiotics are the backbone of treat-
2008;358(9):877-887. ment for HAP and HCAP, but emerging antibiotic resistance
• Sprung CL, Caralis PV, Marcial EH, et al. The effects of high-dose patterns make choice of specific agents—piperacillin/tazobactam,
corticosteroids in patients with septic shock. A prospective, con- late generation cephalosporins, or carbapenems—difficult. The
trolled study. N Engl J Med. 1984;311(18):1137-1143. use of combination therapy and the routine need for MRSA cov-
erage remain controversial.
• De-escalation of antibiotic therapy once the results of cultures are
REFERENCES known is critical for management of ventilated ICU patients with
HCAP and HAP.
Complete references available online at www.mhprofessional.com/hall

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