Nosocomial pneumonia, which includes hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), is associated with high morbidity and mortality. HAP occurs 48 hours or more after admission and may require intubation and mechanical ventilation. VAP occurs more than 48 hours after mechanical ventilation is initiated. The mortality rate of VAP and ventilated HAP ranges from 15% to 30%, depending on severity. Diagnosis is based on a new pulmonary infiltrate associated with clinical evidence of infection such as new-onset fever, purulent sputum, leukocytosis, and decline in oxygenation. Optimal management includes identification of the causative pathogen, early empiric antimicrobial therapy directed against likely pathogens, and de-escalation of treatment once a pathogen is identified. The standard treatment duration is 7 days for patients who are improving clinically. Effective methods to prevent VAP include washing hands adequately between patient contacts, maintaining semirecumbent patient positioning, avoiding gastric overdistention, providing continuous subglottic suctioning for patients on mechanical ventilation, limiting stress-ulcer prophylaxis, and practicing daily oral care with toothbrushing.

Case 2. AB is a 58-year-old man with a history of hypertension and advanced chronic obstructive pulmonary disease who is on day 5 of ventilatory support after surgery for colon cancer. AB has a new-onset fever (101.3°F [38.5°C]) associated with increased purulent endotracheal secretions. His blood pressure is 130/90 mm Hg and pulse is 120/min. Chest radiography reveals new bilateral consolidated infiltrates.