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Apr 14, 2018

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    Hospital-Acquired Pneumonia (HAP) &Ventilator-Associated Pneumonia (VAP)Healthcare-associated pneumonia (HCAP)

    Dr. ANISH M. JOSHI

    ICU REGISTRARCRITICAL CARE DEPARTMENT

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    HCAP

    HAP VAP

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    Definitions

    Healthcare-associated pneumonia (HCAP):

    Arises within 90 days of having beenadmitted to an acute care facility & pt. hasresided in a nursing home or LTCF. OR

    Recd. I.v. antibiotics, chemo or wound care

    within past 30 days HAP:

    Arises 48 hours or more after hospitaladmission

    Is not incubating at the time of admission Ventilator-associated pneumonia (VAP):

    Arises 48-72 hours or more afterendotracheal intubation

    (American Thoracic Society/IDSA. Am J Respir Crit Care Med 2005;171:388-416)

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    HAP: Impact

    Accounts for ~15% of all nosocomialinfections (2ndmost common cause of NIsafter UTIs)

    Extra days in the hospital: 4-9 days

    Average extra days in ICU: 4.3 days

    In mechanically ventilated patients, theincidence increases with duration ofventilation.

    Approximately half of all episodes of VAP occurwithin the first 4 days of mechanicalventilation. The risk is estimated to be3%/day during the first 5 days of ventilation,2%/day during Days 5 to 10 of ventilation,

    and 1%/day after this.

    Incidence

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    Hospital Location & RelativeFrequency of HAP & VAP

    HAP14%

    ICUHAP37.5%

    Non-ICUHAP62.5%

    VAP86%

    Non-ICU HAP

    ICU HAP

    VAP

    ICU HAP

    HAP ICU

    (Kumpf G et al. J Clin Epidemiol 1998;54:495-502)(Lizioli A et al. J Hosp Infect 2003;54:141-148)

    (Richards MJ et al. Crit Care Med 1999;27:887-892)

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    INCIDENCE OF NOSOCOMIAL INFECTIONS INCOMBINED MEDICAL-SURGICAL ICUs

    Medical Patients Surgical Patients

    Pneumonia 30% Pneumonia 33%

    UTI 30% UTI 18%

    Bloodstream SSTI 14%

    infection 16% Bloodstream

    Lower resp. infection 13%

    tract 6% Lower resp.

    (not pneumonia) tract 6%

    (not pneumonia)

    (Richards et al. Infect Control Hosp Epidemiol 2000;21:510-515)

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    Prevention General

    -effective infective control measurestaff education/hand wash/isolation

    -survellianceidentify and quantify endemic and new MDR

    Intubation and mechanical ventilation-avoid if possible

    -non invesive whenever

    -orotracheal intubation and orogastric tube

    -continous aspiration of subglottic secretion

    -cuff pressure 20 mm of H20-Circuit condensate

    -passive humidifier /HME

    -duration of intubation and ventilation

    -avoid constant sedation and paralysis

    -adequate staffing

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    Minimum transport of pt.

    Orotracheal Nasotracheal ET/RTAspiration and feeding

    - PUP 450- Semirecumbent position especially when feeding

    -Enteral Vs Parenteral

    Modulation Colonisation,antiseptic andantibiotic

    -SDD -may reduce VAP /not effective when MDR

    -Prior antibiotic-reduce HAP/if inf in presence of antibiotic suggestMDR

    -Oral Chlorhexidine M/W Other

    -Stress ulcer prophylaxis Sucralfate Vs H2 Blocker

    -Transfusion restricted/leuckocyte depleted

    - Glycemic control

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    Risk Factors Prior antimicrobial therapy in preceding 90 days

    Current hospitalisation of >5 days

    High frequency ofantibiotic resistance in thecommunity or in the specific hospital unit

    Presence of risk factors for HCAP:

    Hospitalisation for >2 days in the preceding 90days

    Residence in a nursing home or extended-carefacility

    Home infusion therapy (including antibiotics) Chronic dialysis within 30 days

    Home wound care

    Family member with MDR pathogen

    Immunosuppressive disease and/or therapy

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    Pathogenesis of

    HAP/VAP

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    Pathogenesis of HAP/VAP

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    Pathogenesis of VAP

    Endogenous and Exogenous Sources

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    Causative Pathogens

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    Classification of HAP & VAP:Risk Stratification

    Time from Hospitalization (days)

    Time from Intubation (days)

    Late-onset HAP

    Early-onset VAP Late-onset VAP

    Early-onset HAP

    0 1 2 3 4 5 6 7

    0 1 2 3 4 5 6 7

    (American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416)

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    Early HAP/VAP Late HAP/VAPBacteriology S. pneumoniae

    H. influenzae

    MSSA

    Susceptible GNB

    E. Coli

    Kleb. Pneumoniae

    Proteus spp.

    Enterobacter spp.

    Serratia marescens

    P. aeruginosa

    Acinetobacter

    MRSA

    Antibiotic resistantEnterobacteriaceae

    Enterobacter spp.

    ESBL +ve strains

    Kleb. Spp.

    Legionella pnemophila

    Burkholderia cepaciaAspergillus spp.

    Prognosis Lesssevere, little impacton outcome

    Mortality minimal

    Higherattributable mortalityand morbidity

    (American Thoracic Society/IDSA. Am J Respir Crit Care Med 2005;171:388-416)

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    Diagnosis of HAP

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    Diagnosis of HAP/VAP

    Chest infiltrate with atleast one clinicalfeature

    -fever-leukocytosis

    -purulent tracheal secretion

    Noninvasive/Clinical approach

    Vs.

    Invasive/Quantitative culture approach

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    Non-invasive/ClinicalCPIS (Clinical Pulmonary Infection Score)

    1. Temperature C Points 38.5 but 38.9 1 39.0 or 36.0 2

    2. TC, mm-3

    < 4,000 or > 11,000 1

    + band forms >50 % 1

    3. Oxygenation: PaO2/FiO2, mm Hg

    < 250 and no evidence ARDS 2

    4. CXR

    Localized infiltrate 2

    Diffuse or patchy infiltrate 1 Progression of infiltrate 2

    5. Culture of tracheal aspirate

    Moderate or heavy growth 1

    Same pathogenic bacteriaon Gram Stain 1

    Max. Score 12

    However

    initially when

    progression of

    infiltrate &

    culture report

    is not known

    max. score can

    be 8-10.

    Most sensitivecomponent isimprovement inoxygenation

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    PSB TRACHEAL

    ASPIRATE

    BAL

    DIAGN.

    THRESHOLD

    103CFU/ML

    105 TO 106CFU/ML

    104 TO 105CFU/ML

    SENSITIVITY 66 76 73

    SPECIFICITY 90 75 82

    MOST SPECIFIC SENSITIVE ACCURATE

    Invasive /Quantitative culture

    More distal the sampling:

    More specific but less sensitive

    Lower the threshold for growth

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    Differential Diagnosis

    Pulmonary oedema

    Pulmonary Contusion &haemorrhage

    Pulmonary embolism

    Hypersensitivity pneumonitisARDS

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    Initial Therapy of

    HAP/VAP

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    Management strategies summaryHAP, VAP or HCAP suspected

    Obtain lower respiratory tract (LRT) sample forculture (quantitative or semi-quantitative) and microscopy

    Unless there is both a low clinical suspicion for pneumonia and negative microscopy of LRT sample, begin

    empiric antimicrobial therapy using an algorithm and local microbiological data

    Days 2 and 3: check cultures and assess clinical response: (temperature, WBC, chest X-ray, oxygenation,

    purulent sputum, haemodynamic changes and organ function)

    Clinical improvement at 4872 hours

    No Yes

    Cultures +Cultures Cultures Cultures +

    Adjust antibiotic therapy,

    search forotherpathogens,

    complications, other diagnosis

    or other sites of infection

    Search forotherpathogens,

    complications, other diagnoses

    or other sites of infection

    Consider stopping

    antibiotics

    De-escalate antibiotics,

    if possible, treat

    selected patients for

    7

    8 days and re-assessATS/IDSA Guidelines. Am J Respir Crit Care Med 2005;171:38841

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    Empiric antibiotic therapy

    ATS/IDSA Guidelines. Am J Respir Crit Care Med 2005;171:388416

    HAP or VAP suspected

    (all disease severities)

    Late-onset or risk factorsfor MDR pathogens

    NO YES

    Narrow-spectrum

    antibiotic therapy

    Broad-spectrum

    antibiotic therapy

    Initial empiric therapy no known risk

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    Initial empiric therapy, no known riskfactors for MDR pathogens, early onsetand any disease severity

    Ceftriaxone

    (2g OD )

    OR

    Levofloxacin(750 mg OD),Moxifloxacin(400 mg OD)

    or Ciprofloxacin (400 mg TDS)

    OR

    Ampicillin/sulbactam( 3 g QID)

    OR

    Ertapenem (1 g OD)

    All i.v

    I iti l i i th i ti t ith l t

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    Initial empiric therapy in patients with lateonset or risk factors for MDR pathogens, andany disease severity

    Cephalosporin

    ORCarbapenem

    OR

    -lactam/-lactamase inhibitor

    PLUS

    FluoroquinoloneOR

    Aminoglycoside

    PLUSLinezolid (600 mg/kg BD)

    or Vancomycin (15 mg/kg upto 1 g BD)(if MRSA risk factors are present or there

    is a high incidence locally)

    Cefepime ( 2g OD )Ceftazidime (2 g TDS)

    Imipenem (500 mg QID or 1 g TDS)Meropenem ( 1 g TDS)

    Piperacillin/tazobactam (4.5 g QID)

    Ciprofloxacin (400 mg TDS)Levofloxacin (750 mg OD)

    Amikacin (20 mg/kg OD)

    Gentamicin or Tobramycin

    (7 mg/kg OD)

    All I.V.

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    Factors afffecting results

    Penetration ----fluroquinolone,linezolide best

    ----Beta lactam less Mechanism of action

    ---concentration dependent-aminoglycoside,quinolone

    ---time dependent-vancomycin,Beta lactam

    Post antibiotic effect

    for gram negativeaminoglycoside,quinolone- prolong

    --beta lactam- no/short (exceptcarbepenem)

    Beta lactam---frequent dosing

    Aminoglycoside,quinolone---single daily dose

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    Optimal antibiotic therapy

    Shorten the duration from 14-21 days to 8days unless the pathogen is not pseudomonasaeruginosa or patient has poor clinical

    response. Initial iv oral/enteral with good response &

    fning int. tract

    Combination therapy for MDR pathogens

    Cycling antibiotics within the same class may antibiotic resistance

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    Resolution Microbiological

    --serial culture--end point-bacterial

    eradication,superinfection,recurrentinfection,microbiological persistence

    --PSB -50% ,cavitydevelop,significant pleural effusion

    Clinical

    --core temp,WBC,oxygenation

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    Deterioration or Nonresolution

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    CX

    length of stay in ICU/Hosp. Expensive

    Necrotizing pneumonia with risk ofpul. hrrage

    Prolonged rehabilitation due to

    muscle loss particluarly in elderly Death

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    THANKYO

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    RiskFactors(contd.)Co-morbid

    IllnessesICU Therapies Injuries Ventilation

    Cancer

    COPD

    Chronic cardiacdisease

    Kidney failure

    CPR

    Corticosteroid use

    General surgery

    Neurosurgery

    Antacids Paralytic agents

    Tracheostomy

    RT

    Large-volumegastric aspiration

    Burns

    Coma

    Head injury

    MODS

    ARDS

    Duration ofmechanicalventilation

    Intracuff pressure