| Type | Setting | Common Pathogens | Key Feature |
|---|
| CAP (Community-Acquired) | Before or ≤48h after admission | S. pneumoniae (#1), H. influenzae, Mycoplasma, Legionella, viruses | Usually starts outpatient; chest X-ray lobar or bronchopneumonia pattern |
| HAP (Hospital-Acquired) | ≥48h after admission; NOT intubated | MRSA, Pseudomonas, gram-negative bacilli | Resistant organisms more likely; typically sicker baseline patients |
| VAP (Ventilator-Associated) | ≥48h after intubation | MRSA, Pseudomonas, Acinetobacter, Klebsiella | Most severe; 20–50% mortality; bundle prevention is standard of care |
| HCAP (Health Care-Associated) | Recent hospitalization, dialysis, nursing home | Similar to HAP; resistant organisms | Now classified under HAP in most guidelines |
| Aspiration Pneumonia | After aspiration of oral/gastric contents | Mixed anaerobes; gram-negatives | Right lower lobe most common; occurs in dysphagia, altered LOC, tube feeding patients |
| Atypical ("Walking") Pneumonia | Community; often younger patients | Mycoplasma, Chlamydia, Legionella | Gradual onset; minimal infiltrates; does NOT respond to beta-lactams; needs macrolide/doxycycline |
| Finding | What It Indicates |
|---|
| Dullness to percussion | Fluid/consolidation in alveoli |
| Bronchial breath sounds over peripheral lung | Consolidation (normally only heard over trachea) |
| Egophony ("E to A" — say "E," sounds like "A") | Consolidation |
| Increased tactile fremitus | Consolidation (fluid transmits vibration) |
| Crackles (fine, late-inspiratory) | Fluid in alveoli; opening of collapsed alveoli |
| Reduced or absent breath sounds | Pleural effusion or complete consolidation |
| Bundle Element | Specific Action |
|---|
| HOB elevation | 30–45° at ALL times unless contraindicated |
| Daily sedation vacation | Hold sedation daily; assess readiness for extubation |
| Daily extubation readiness | Spontaneous breathing trial (SBT) daily if clinically appropriate |
| Oral care | Chlorhexidine 0.12% oral rinse q4–8h; oral suctioning; teeth brushing |
| Subglottic suctioning | Continuous or intermittent suction above cuff; removes pooled secretions |
| Cuff pressure maintenance | 20–30 cmH2O; prevents microaspiration around cuff |
| Hand hygiene | Before and after every vent circuit interaction |
| Stress ulcer prophylaxis | PPI or H2 blocker as ordered |
| DVT prophylaxis | LMWH or SCDs; reduce mortality |
| Setting | Typical Regimen |
|---|
| Outpatient CAP (healthy, no comorbidities) | Amoxicillin 1g TID OR doxycycline 100mg BID × 5 days |
| Outpatient CAP (comorbidities) | Amoxicillin-clavulanate + azithromycin OR respiratory fluoroquinolone (levofloxacin) |
| Inpatient CAP (non-ICU) | Beta-lactam (ceftriaxone) + macrolide (azithromycin) OR respiratory FQ alone |
| Inpatient CAP (ICU) | Beta-lactam + azithromycin + vancomycin or linezolid (MRSA coverage) |
| HAP/VAP (no MRSA risk) | Piperacillin-tazobactam or cefepime or carbapenem |
| HAP/VAP (MRSA risk) | Add vancomycin or linezolid |
| Atypical pneumonia | Azithromycin 500mg day 1, then 250mg × 4 days; OR doxycycline; OR respiratory FQ |