Reduce Your Risk of Getting Pneumonia in the Hospital

Of course, no one wants to get sicker while in the hospital. Unfortunately, that is exactly what happens to many patients who get pneumonia in the hospital. The impact of pneumonia ranges from mild to life threatening, so it’s worth your time to learn more about pneumonia, how you can get it, and what you can do to reduce your risk of pneumonia in the hospital.

What is pneumonia?

Pneumonia is an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus, causing cough with phlegm or pus, fever, chills, and difficulty breathing.

How does pneumonia develop?

A variety of germs, including bacteria, viruses and fungi, can get into your lungs and cause pneumonia. Most people who get pneumonia get it from bacteria and viruses in the air. Although our bodies usually prevent these germs from infecting our lungs, sometimes these germs can overpower our immune systems.

What are the symptoms of pneumonia?

Misdiagnosis of pneumonia can harm patients.

A study published in 2024 examined 17,000 hospitalized patients across 48 hospitals in Michigan. Researchers found that about 12% of patients were inappropriately diagnosed with community-acquired pneumonia (CAP).

Interestingly, older people, as well as patients with dementia and other altered mental status had a particularly high risk of getting an incorrect diagnosis of pneumonia.

The misdiagnosis of CAP can harm patients in several ways:

• Doctors can miss what is actually wrong with the patients, which can worsen without appropriate treatments.
• Patients receive unnecessary antibiotics with can lead to medication-related adverse events.

If you or a loved one (particularly a patient with cognitive decline) receive a pneumonia diagnosis, ask about getting a chest x-ray to confirm the diagnosis. And ask the doctor if there could be any other explanation of symptoms. Finally, ask for a reassessment in 2-3 days, the current recommended guidelines for a pneumonia diagnosis.

How dangerous is pneumonia?

The impact of pneumonia can range from mild to life-threatening. Pneumonia is most dangerous for infants and young children, those 65+, and people with other health problems or weakened immune systems.

Possible complications from pneumonia include:

• Respiratory failure, which requires a breathing machine or ventilator.
• Sepsis, a condition marked by uncontrolled inflammation in the body, which may lead to widespread organ failure.
• Acute respiratory distress syndrome (ARDS) – a severe form of respiratory failure.
• Rare, but serious lung abscesses which occur when pockets of pus form inside or around the lung. Some patients require surgery to drain the pus.

How do doctors treat pneumonia?

If you get pneumonia, your treatment plan will depend on the type of pneumonia you have, the severity of the infection, your age, and your overall health. For mild cases, you should recover at home by following your doctor’s orders.

However, if you develop a severe case of pneumonia, and/or you have other serious medical conditions, you may need hospitalization. In this case, your treatment may include IV fluids, antibiotics, oxygen therapy, and other breathing treatments.

Where can you get pneumonia?

There are 4 primary avenues for getting pneumonia, as follows:

In your community.

The most common type of pneumonia occurs outside of hospitals or other healthcare facilities. Community-acquired pneumonia is generally caused by bacteria, bacteria-like organisms, fungi, and viruses (including viruses that cause colds, the flu, and COVID-19).

From aspiration.

You can get aspiration pneumonia when you inhale food, drink, vomit, or saliva into your lungs. This is particularly a problem for people who have difficulty swallowing, due to physical or cognitive illnesses.

In non-hospital healthcare settings.

In addition to hospital-based cases, people can get pneumonia in other healthcare facilities, such long-term care facilities, and outpatient clinics, including dialysis centers. Like hospital-acquired pneumonia, the bacteria that cause healthcare-acquired pneumonia can be more resistant to antibiotics.

In the hospital.

As the term suggests, when patients get pneumonia while in the hospital, it’s called hospital-acquired pneumonia. Unfortunately, pneumonia that starts in the hospital tends to be more serious than other lung infections because:

• People in the hospital are often very sick and cannot fight off germs.
• The types of germs present in a hospital are often more dangerous and more resistant to treatment than germs outside in the community.

The rest of this post focuses on hospital-acquired pneumonia and how to reduce your risk of getting pneumonia in the hospital.

What is the cause of hospital-acquired pneumonia?

Hospital-acquired pneumonia occurs when germs get into the lungs of hospital patients. There are two categories of pneumonia associated with hospital stays – ventilator-associated pneumonia and non-ventilator pneumonia. Both pose serious threats to patients.

What factors increase your risk of getting pneumonia in the hospital?

You’re more likely to get pneumonia while in the hospital if you:

• Are on a ventilator.
• Abuse alcohol.
• Have had chest surgery or other major surgery.
• Have a weak immune system from cancer treatment, certain medicines, or severe wounds.
• Have chronic lung disease.
• Breathe saliva or food into your lungs, usually because you are not fully alert or have swallowing problems.
• Are not mentally alert due to medicines or illness.
• Are older.

Is it common to get pneumonia in the hospital?

Pneumonia is among the most common infections that occur in healthcare facilities.

Ask about pneumonia control programs before you go!

If time allows, ask your doctor or hospital about their protocols for reducing the incidence of both ventilator-associated and non-ventilator pneumonia. When possible, choose a hospital with a strong program in place.

Non-ventilator hospital-acquired pneumonia (NVHAP)

Although you may have heard stories of patients on ventilators developing pneumonia, it turns out that most hospitalized patients who get pneumonia are not on ventilators. When patients who are not on ventilators get pneumonia, it’s referred to as non-ventilator hospital-acquired pneumonia (NVHAP).

How common is NVHAP?

This pneumonia infects about 1 in every 100 hospital patients.

How dangerous is NVHAP?

Unfortunately, NVHAP kills 15-30% of infected patients.

Moreover, for those who survive, the pneumonia often leads to an additional stay in the hospital – as much as 15 more days. And NVHAP makes hospital readmission (within a month) or a transfer to an intensive care unit much more likely.

How do patients get NVHAP?

Patients often get NVHAP from the bacteria in their mouths that gathers on their unbrushed teeth, which is then transferred to the lungs by breathing. Oral bacteria are more common than you might realize. In fact, one study found disease-causing bacteria, especially germs that can cause pneumonia, in 90% of patients within 72 hours of their admission to the hospital.

Yes, bacteria can travel from your mouth to your lungs when you’re not in the hospital. However, you’re more at risk of getting pneumonia this way while in a hospital. Why? Firstly, hospitals often expose patients to a toxic mix of bacteria. Secondly, immobility and medications that dry out the mouth or suppress coughs increase the risk of developing pneumonia. Finally, you’re less likely to have consistent tooth brushing while in the hospital.

Additionally, patients can get pneumonia from germs carried by healthcare workers on their hands, clothes, or instruments, transferring germs from one patient to another.

What increases risk for NVHAP?

Unfortunately, virtually all patients are at risk for contracting NVHAP.

However, there are factors that increase a patient’s risk:

• Lying flat or remaining immobile for long periods.
• Lack of proper, regular tooth brushing/oral care.
• Difficulty swallowing (dysphagia).

Can hospitals prevent NVHAP?

Although the US government requires hospitals to report many hospital-acquired infections, that is not the case for NVHAP. Therefore, few hospitals understand the origin of the illness, track its occurrence, or actively work to prevent it.

However, a few recent studies show that hospitals can reduce rates of NVHAP by focusing on consistent tooth brushing (which significantly reduces the number of bacteria in the mouth) and getting patients out of bed.

Importantly, these studies are small. Plus the impact of the training of the person providing the oral care (nurse, dental expert) and the type of oral care (e.g., mouthwash vs. toothbrushing, manual vs. electric toothbrush) is unclear. But it is promising!

For instance, in a report published in 2024, an analysis of 15 randomized clinical trials (over 2,700 patients) found that hospital-acquired pneumonia rates were lower among patients who had daily toothbrushing, particularly among patients receiving invasive mechanical ventilation.

Similarly, a study at 21 California Kaiser Permanente hospitals found that by prioritizing oral care and getting patients out of bed reduce their rates of hospital-acquired pneumonia by around 70%. Additionally, at Sutter Medical Center in Sacramento, improving oral hygiene reduced NVHAP cases by a yearly average of 35%.

And Florida’s Orlando Regional Medical Center reduced NVHAP rates in a medical unit by 85%, and in a surgical unit by 56%, by enhancing oral care for patients.

Lastly, at a veterans’ hospital in Salem, Virginia, a 2016 oral care pilot program reduced rates of NVHAP by 92% — saving an estimated 13 lives in just 19 months. This success led to an expansion of the program across the Veterans Health Administration.

How can you reduce your risk of getting non-ventilator pneumonia in the hospital?

Fortunately, it’s fairly easy to lower your (or a loved one’s) risk of developing NVHAP. Patients should:

• Keep the head elevated by raising the head of the bed.
• Get out of bed throughout the day. Importantly, talk to your doctor and/or nurse before getting out of bed by yourself! Falls in hospitals are common and dangerous.
• Brush your teeth properly at least twice a day**. Importantly, if your illness makes it hard to brush your own teeth, ask your nurse to brush them for you. Since you may not find a suitable toothbrush or toothpaste in your hospital’s personal care packet, bring a toothbrush and toothpaste from home (or have a loved one bring you these after your admission). In addition to toothbrushing, you also may want to use an antiseptic mouthwash, particularly if you have an elevated risk for pneumonia.
• If you (or your loved one) have difficulty swallowing, talk to your medical team about possible treatments.
• Make sure all providers and guests wash their hands before touching you (or your loved one) or any medical equipment, furnishings, or supplies. As a patient or family caregiver, don’t feel shy about asking others to comply!

Note that if your loved one cannot speak up for themselves, you should intervene on his/her behalf.

Ventilator-associated pneumonia (VAP).

Patients on ventilators, often used in intensive care units, have a higher risk of getting pneumonia – referred to as ventilator-associated pneumonia (VAP).

How common is VAP?

Research shows incidents of VAP among mechanically ventilated patients varies between 5 to 40% depending on the setting and diagnostic criteria.

How dangerous is VAP?

Frighteningly, the mortality rate of VAP generally ranges between 25% – 50%. However, it can increase to 70% in some situations. In fact, it’s the most frequent life-threatening infection to develop in intensive care units. As such, VAP is one of the most feared infections that can develop in a hospital patient.

How do patients get VAP?

Ventilators provide oxygen to patients through a tube placed in the patients’ mouth, nose, or hole in the front of the neck. These tubes provide germs an easy path into the lungs.

Can hospitals prevent VAP?

The Centers for Disease Control and Prevention (CDC) recommends hospitals take the following steps to prevent ventilator-associated pneumonia:

• Keep the head of the patient’s bed raised (unless other medical conditions make this impossible).
• Check a patient’s breathing every day to see if the patient no longer needs the ventilator.
• Thorough hand washing by staff (with soap and water or an alcohol-based hand rub) before and after touching each patient and/or the ventilator.
• Clean the inside of the patient’s mouth on a regular basis.

These prevention programs can make a difference.

For instance, a VAP prevention program implemented in 118 ICU departments in hospitals throughout Spain led to a 50% reduction in the incidence of ventilator-associated pneumonia. The program required “mandatory” and “highly recommended” measures, including regulated oral hygiene for patients, improved hand hygiene for staff, and protocols to limit time on ventilation.

Similarly, a VAP prevention program in at a hospital in Saudi Arabia led to a 76% reduction of VAP rates. This program included routine infection control protocols, elevating the heads of the beds, daily “sedation vacations”, regular assessments of a patient’s need for a ventilator, and more.

How can you reduce your risk of getting pneumonia associated with ventilators?

If your loved one is on a ventilator, you must speak up and take steps on their behalf to reduce his/her risk of VAP, including:

• Ask staff about elevating the head of the bed.
• Every day, ask staff when your loved one can try breathing on his or her own, with the goal of getting off the ventilator as soon as possible.
• Ask staff to brush your loved one’s teeth properly at least twice a day**. Since you may not find a suitable toothbrush or toothpaste in your hospital’s personal care packet, bring them from home. Additionally, ask about the use of an antiseptic mouthwash.
• Make sure all providers and guests wash their hands before touching your loved one or any medical equipment, furnishings, or supplies. Don’t feel shy about asking others to wash their hands if you don’t see them do it!

**Patients may require different types of oral care depending on their medical condition. Use the chart developed by Sutter Medical Center in conjunction with their local dental society to find the proper oral care protocol for yourself or a loved one (see page 4 of their PDF).

Learn more…

To learn more about germs and hospital infections, read these posts:

• Why is Sepsis So Dangerous?
• Germs in Hospitals and Doctor Offices – Watch Out!
• Protect Yourself from Superbugs.
• How To Protect Yourself from Hospital Infections.
• Handwashing in Healthcare Could Save Your Life!
• What’s Your Hospital’s Safety Record? Is Your Hospital Safe?

NOTE: I updated this post on 6-8-24.