Hospital-acquired pneumonia diagnostic algorithm

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Diagnostic Algorithm

Shown below is an algorithm for the diagnostic approach of Healthcare-associated pneumonia (HCAP), Ventilator-associated pneumonia VAP), and Hospital-acquired pneumonia (HAP).[1]

High suspicion of HAP, VAP or HCAP
Obtain sputum or respiratory secretions sample for culture and microscopy
Does the patient has any of the following risk factors for MDR infection?
  • Antimicrobial therapy in preceding 90 days
  • Current hospitalization of ≥ 5 days
  • High frequency of antibiotic resistance in the community or in the specific hospital unit
  • Immunosuppressive disease and/or therapy
  • Presence of risk factors for HCAP:
  • Hospitalization ≥2 days in the preceding 90 days
  • Residence in a nursing home or extended care facility
  • Home infusion therapy (including antibiotics)
  • Chronic dialysis within 30 days
  • Home wound care
  • Family member with multidrug-resistant pathogen
Start empirical therapy with combined broad spectrum antibiotics
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Start empirical therapy with limited spectrum antibiotics
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After 2-3 days, check cultures and assess the clinical response based on:
Does the patient improved his clinical status after 48-72 hours?
Assess culture results
Assess culture results
Positive Culture
Negative Culture
Positive Culture
Negative Culture
De-escalate antibiotics, treat for 7-8 more days and re-evaluate
Consider stopping antibiotics
Adjust antibiotic regimen based on culture susceptibility, look for other infection sites and complications
Look for other pathogens, infection sites and complications


  1. "Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia". American Journal of Respiratory and Critical Care Medicine. 171 (4): 388–416. 2005. doi:10.1164/rccm.200405-644ST. ISSN 1073-449X.