Ventilator Associated Infections VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

7/28/2019 Ventilator Associated Infections VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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VENTILATOR ASSOCIATED

PNEUMONIACARE AND PREVENTION

Dr.T.V.Rao MD

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Introduction to Patient Safety:

Definition Patient safety is a discipline in the health

care sector that applies safety science

methods toward the goal of achieving atrustworthy system of health care

delivery. Patient safety is also an

attribute of health care systems; it

minimizes the incidence and impact of,

and maximizes recovery from, adverse

events (Emanuel et al., 2008) .Dr.T.V.Rao MD 2


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Introduction to Patient Safety:

Background

Adverse medical events are widespread

and preventable (Emanuel et al., 2008) .

Much unnecessary harm is caused by

health-care errors and system failures.

Ex. 1: Hospital acquired infections from

poor hand-washing. Ex. 2: Complications from administering

the wrong medication.

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Required Attitudes

Being an effective team player.

Commitment to preventing HAIs

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ICU patients

Sickest patients (multiple diagnoses,multi-organ failure,immunocompromised, septic and

trauma)

Move less

Malnourished

More obtunded (Glasgow coma scale)

Diabetics and Heart failure

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ICU patients

Sickest patients (multiple diagnoses,multi-organ failure,immunocompromised, septic and

trauma)

Move less

Malnourished

More obtunded (Glasgow coma scale)

Diabetics and Heart failure

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Remember Some One at Risk with

Ventilator

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Who is Responsible for Ventilator care

The registered nurse is responsible for the

assessment, planning and delivery of care to

the patient.

Care of the ventilated patient can vary from

the basic nursing care of activities of daily

living to caring for highly technical invasive

monitoring equipment and managing andmonitoring the effects of interventions.

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Basic Observations

Ensure the

endotracheal tube

(ETT) or

tracheostomy tube is

held securely in

position but not too

tightly to result inpressure area

lesions.

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Always check the patient first.

Observe the

patients facial

expression,colour,

respiratory

effort, vital signs

and ECG tracing.

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What is Mechanical Ventilator

MechanicalVentilation isventilation of the

lungs by artificialmeans usually by aventilator.

A ventilator delivers

gas to the lungswith either negativeor positivepressure.

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Purposes: To maintain or

improve

ventilation, &

tissueoxygenation.

To decrease the

work of breathing

& improve

patients comfort.Dr.T.V.Rao MD 12


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Intensive Care Unit

Nosocomial Pneumonia

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VENTILATOR ASSOCIATED PNEUMONIA

(VAP)

VAP is the leading cause of nosocomial

infection in the ICU and reflects 60% of

all deaths attributable to nosocomialinfections.

Pneumonia rates are much higher in

mechanically ventilated patients due tothe artificial airway, which increases the

opportunity for aspiration and

colonization. Dr.T.V.Rao MD 14


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Definition- Know thy enemy

Pneumonia that develops in someone who has beenintubated

-Typically in studies, patients are only included ifintubated greater than 48 hours

-Early onset= less than 4 days-Late onset= greater than 4 days

Endotracheal intubation increases risk of developing

pneumonia by 6 to 21 fold

Accounts for 90% of infections in mechanicallyventilated patients

American Thoracic Society, Infectious Diseases Society of America.

Guidelines for the management of adults with hospital-acquired, ventilator-associated,

and healthcare-associated pneumonia.Dr.T.V.Rao MD 15


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Who gets VAP? (Risk factors)

Study of 1014 patients receiving mechanical

ventilation for 48 hours or more and free of

pneumonia at admission to ICU

Increased risk associated with admitting diagnosis of:

Burns (risk ratio=5.09)

Trauma (risk ratio=5.0)

Respiratory disease (risk ratio=2.79)

CNS disease (risk ratio=3.4)

Cook et al. Incidence of and risk factors for ventilator-associated pneumonia

in critically ill patients. Dr.T.V.Rao MD 16


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Risk factors for bacterial

pneumoniaHost Factors Factors that facilitate reflux

& aspiration into the lower RT Elderly Severe Illness Underlying Lung Disease - Mechanical ventilation

Depressed Mental Status - Tracheostomy Immunocompromising - Use of a Nasogastric Tube

Conditions or Treatments - Supine Position Viral Respiratory Tract Factors that impede normal

Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgery

Intensive Care Setting - Immobilisation Use of Antimicrobial Agents Contaminated hands Contaminated Equipment

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Incidence of VAP

The exact incidence of HAP is usually between 5

and 15 cases per 1,000 hospital admissions

depending on the case definition and study

population; the exact incidence of VAP is 6- to 20-fold greater than in nonventilated patients

(Level II)

HAP accounts for up to 25% of all ICU infections In ICU patients, nearly 90% of episodes of HAP

occur during mechanical ventilation

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Resistant Bacteria leading Cause

Many patients

with HAP, VAP, and

HCAP are atincreased risk for

colonization and

infection withMDR pathogens(Level II)

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Pathogenesis

Where do the bacteria come from?

Tracheal colonization- via oropharengeal

colonization or GI colonization

Ventilator system

How do they get into the lung?

Breakdown of normal host defenses

Two main routes

Through the tube

Around the tube- micro aspiration around ETT cuff

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Etiology Bacteria cause most cases of HAP, VAP, and

HCAP and many infections are polymicrobial;rates are especially high in patients with ARDS(Level I)

HAP, VAP, and HCAP are commonly caused byaerobic gram-negative bacilli, such as P.aeruginosa, K. pneumoniae, andAcinetobacter

species, or by gram-positive cocci, such as S.aureus, much of which is MRSA; anaerobes arean uncommon cause of VAP (Level II)

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Predisposing causes in Pneumonia

Pseudomonas aeruginosa. the most common MDR gram-negative bacterial

pathogen causing HAP/VAP, has intrinsic resistance tomany antimicrobial agents

Klebsiella, Enterobacter, and Serratia species. Klebsiella species

intrinsically resistant to ampicillin and other aminopenicillinsand can acquire resistance to cephalosporins and aztreonamby the production of extended-spectrum lactamases (ESBLs)

ESBL-producing strains remain susceptible to carbapenems

Enterobacterspecies

Citrobacterand Serratia species

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Acinetobacter species

More than 85% of isolates are susceptible to

carbapenems, but resistance is increasing

An alternative for therapy is sulbactam

Stenotrophomnonas maltophila, and

Burkholderia cepacia:

resistant to carbapenems susceptible to trimethoprimSulphmethoxazole,

Ticarcillinclavulanate, or a fluoroquinolone

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Methicillin-resistant Staphylococcus aureus

Vancomycin-intermediate S. aureus

sensitive to linezolid

linezolid resistance has emerged in S. aureus, but is currently

rare

Streptococcus pneumoniae and Haemophilus

influenza.

sensitive to Vancomycin or linezolid, and most remainsensitive to broad-spectrum quinolones

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Initiation of Mechanical

Ventilation

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Guidelines in the Initiation of

Mechanical Ventilation

Primary goals of mechanical ventilation areadequate oxygenation/ventilation, reduced workof breathing, synchrony of vent and patient, and

avoidance of high peak pressures Set initial FIO2 on the high side, you can always

titrate down

Initial tidal volumes should be 8-10ml/kg,

depending on patients body habitus. If patient isin ARDS consider tidal volumes between 5-8ml/kgwith increase in PEEP

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Guidelines in the Initiation of

Mechanical Ventilation

Use PEEP in diffuse lung injury and ARDS to

support oxygenation and reduce FIO2

Avoid choosing ventilator settings that limit

expiratory time and cause or worsen auto PEEP

When facing poor oxygenation, inadequate

ventilation, or high peak pressures due to

intolerance of ventilator settings considersedation, analgesia or neuromuscular blockage

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Ventilators After every patient,

clean and disinfect

(high-level) or

sterilize re-usablecomponents of the

breathing system or

the patient circuitaccording to the

manufacturers

instructions. Dr.T.V.Rao MD 28


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Suctioning mechanically

ventilated patients

Hand washing before and after the procedure.

Wear clean gloves to prevent cross-

contamination

Use a sterile single-use catheter ; if it is not

possible then rinse catheter with sterile water

and store it in a dry, clean container between

uses and change the catheter every 8 - 12

hours.

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Suction Bottle Use single-use

disposable, if possible

Non-disposable bottles

should be washed withdetergent and allowed

to dry. Heat disinfect in

washing machine or

send to Sterile ServiceDepartment.

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Nebulizers Use sterile medications and fluids for nebulization

Fill with sterile water only.

Change and reprocess device between patients byusing sterilization or a high level disinfection oruse

single-use disposable item. Small hand held nebulizers

minimise unnecessary use

between uses for the same patient disinfect, rinse

with sterile water, or air dry and store in a clean,dry place

Reprocess nebulizers daily

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Humidifiers

Clean and sterilize device between

patients.

Fill with sterile water which must bechanged every 24 hours or sooner, if

necessary.

Single-use disposable humidifiers are

available but they are expensive.Dr.T.V.Rao MD 32


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Ventilator cleaning and

Decontamination

After every patient,

clean and disinfect

(high-level) or

sterilize re-usablecomponents of the

breathing system or

the patient circuitaccording to the

manufacturers

instructions.Dr.T.V.Rao MD 33


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If put on Oxygen mask

Change oxygen

mask and tubing

betweenpatients and

more frequently

if soiled

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Prevalence of VAP

Occurs in 10-20% of

those receiving

mechanical

ventilation forgreater than 48

hours

Rate= 14.8 cases per1000 ventilator days


in critically ill patients.

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When does VAP occur?

Cook et al showed . . .

40.1% developed before day 5

41.2% developed between days 6 and 10 11.3% developed between days 11-15

2.8% developed between days 16 and 20

4.5% developed after day 21


in critically ill patients.Dr.T.V.Rao MD 36


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Time frame of intubation and risk

Risk of pneumonia

at intubation days

3.3% per day atday 5

2.3% per day at

day 10

1.3% per day at

day 15Cook et al. Incidence of and risk factors for ventilator-associated pneumonia

in critically ill patients.Dr.T.V.Rao MD 37

C i R l f S b l i


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Dr.T.V.Rao MD 38

Continuous Removal of Subglottic

Secretions

Use an ET tube withcontinuous suctionthrough a dorsal

lumen above thecuff to preventdrainageaccumulation.

CDC Guideline for Prevention of

Healthcare Associated Pneumonias

2004 ATS / IDSA Guidelines for VAP

2005


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Dr.T.V.Rao MD 39

HOB Elevation

HOB at 30-45

CDC Guideline for Prevention of Healthcare Associated Pneumonias2004 ATS / IDSA Guidelines for VAP 2005

HOB El ti


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Dr.T.V.Rao MD 40

HOB ElevationReferences

HOB at 30-45

Torres et al,Annals of Int Med1992;116:540-543

Ibanez et al.JPEN 1992;16:419-422

Orozco-Levi et al.Am J Respir Crit Care Med1995;152:1387-1390

Drakulovic et al. Lancet1999;354:1851-1858

Davis et al. Crit Care 2001;5:81-87

Grap et al.Am J of Crit Care 2005 14:325-332


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HOB UP 30 DEGREES OR HIGHER

Recommended elevation is 30-45 degrees

If semi-recumbent or supine 34% incidence VAP

If semi-recumbent position 8% incidence VAP*

HOB risk of aspiration of gastrointestinalcontents

risk of aspiration of oropharengealsecretions

risk of aspiration of nasopharyngealsecretions

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HOB UP 30 DEGREES OR HIGHER

HOB improves patientsventilation

Supine patients havelower spontaneous tidalvolumes on PS

than those seated inupright position

HOB may aidventilatory efforts andminimize atelectasis

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HOB El i L d


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Ventilator Associated

Pneumonia (VAP)Practice Alert

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HOB Elevation Leads to

Significant Deduction in VAP

Dravulovic et al. Lancet

1999;354:1851-1858

0

5

10

15

20

25

%V

AP

Supine HOB Elevation

Frequency of


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Dr.T.V.Rao MD 44

CDC Guideline for Prevention of Healthcare AssociatedPneumonias 2004

Frequency of

Equipment Changes

Ventilator

Tubing

AmbuBags

Inner

Cannulas of

Trachs

No Routine

Changes

Between

PatientsNot

Enough

Data


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Dr.T.V.Rao MD 45

Hand washing

What role does hand washing play

in nosocomial pneumonias?

Albert, NEJM 1981; Preston, AJM 1981;

CDC Guideline for Prevention of Healthcare Associated

Pneumonias 2004


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Ventilator Associated

Pneumonia (VAP)Practice Alert

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VAP Prevention and Hand Washing

Wash hands or use an alcohol-based waterless antiseptic agentbefore and after suctioning,touching ventilator equipment,and/or coming into contact withrespiratory secretions.

CDC Guideline for Prevention of Healthcare Associated Pneumonias

2004

AACN Practice Alert for VAP, 2007

S ti i h i ll


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Suctioning mechanically

ventilated patients

Hand washing before and after the procedure.

Wear clean gloves to prevent cross-

contamination

Use a sterile single-use catheter ; if it is not

possible then rinse catheter with sterile water

and store it in a dry, clean container between

uses and change the catheter every 8 - 12hours.

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VAP Reduction with ET Suction

Above the Cuff

0

5

10

15

20

Pe

rcent(%)

No Suction Suction

Ventilator Associated Pneumonia(VAP) Practice Alert 48

Smulders et al.Chest;121:858-862


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Suction Bottle

Use single-use

disposable, if possible

Non-disposable bottles

should be washed withdetergent and allowed

to dry. Heat disinfect in

washing machine or

send to Sterile ServiceDepartment.

Dr.T.V.Rao MD 49


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Nebulizers

Use sterile medications and fluids for nebulization Fill with sterile water only.

Change and reprocess device between patients byusing sterilization or a high level disinfection oruse

single-use disposable item. Small hand held nebulizers

minimise unnecessary use

between uses for the same patient disinfect, rinse

with sterile water, or air dry and store in a clean,dry place

Reprocess nebulizers daily

Dr.T.V.Rao MD 50


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Humidifiers

Clean and sterilize device between

patients.

Fill with sterile water which must bechanged every 24 hours or sooner, if

necessary.

Single-use disposable humidifiers areavailable but they are expensive.

Dr.T.V.Rao MD 51

Indications for an actively humidified


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Indications for an actively humidified

circuit (Westmead ICU)

minute volume greater than 10 litres

chest trauma with pulmonary contusion

airway burns

severe asthma hypothermia (


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Pooling of Secretions

Pooled secretions above the ETT/trachi cuff

are associated with ventilator associated

pneumonia (VAP). This is a result of aspiration

of bacteria colonizing the oropharynx or GITand subsequently leaking below the cuff into

the trachea. Therefore thorough

oropharyngeal suctioning should beperformed before letting down the cuff to

reposition the ETT or to check cuff pressure.

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Suction of an Artificial Airway

To maintain a patent airway

To promote improved gas exchange

To obtain tracheal aspirate specimens

To prevent effects of retained secretions eg.

infection, consolidation , atelectasis, increased

airway pressures or a blocked tube.

It is important to oxygenate before and after

suctioning

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Sterilisation and decontamination

After use, the patient circuit should bedetached from the ventilator anddisassembled to expose all surfaces prior to

cleaning.Thoroughly clean to remove all blood,

secretions, thick mucus and other residue.

You may use multi enzyme cleaner.

Medical detergent solution can also be usedto thoroughly to flush the tubing's.

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Contd

2% Glutaraldehyde is used for routinesterilisation of tubing's and otheraccessories.

Please follow manufacturers directions andrecommendations.

Ethylene Oxide gas sterilisation is also

used. Ethylene oxide may cause superficialcrazing of plastic components and willaccelerate the aging of rubber components.

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Contd

Ensure complete dryness of the tubes

before sending for gas sterilisation as

ethylene glycol may be formed which is

poisonous.

After sterilisation, the tubing's must be

properly aerated to dissipate residualgas absorbed by the materials.

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Dr.T.V.Rao MD 59

VAP Protection

Use a continuous subglotticsuction ET tube for intubationsexpected to be > 24 hours

Keep the HOB elevated to at least30 degrees unless medically

contraindicatedCDC Guideline for Prevention of Healthcare Associated Pneumonias

2004

AACN Practice Alert for VAP, 2007


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Hand Hygiene

leading cause of infection in health care

settings is the lack of proper hygiene practices

by health care professionals. The CDC VAP

protocol guidelines recommend improvedhand hygiene practices by health care workers

including alcohol based antiseptic solutions.

Changing disposable gloves and washing thehands before putting on another pair can also

lower the risk of VAP.

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How to use waterless hand rub

Apply a palmful of product in cupped hand Rub hands palm to palm

Right palm over left hand with interlaced fingers

Palm to palm with fingers interlaced

Backs of fingers to opposing palms with fingersinterlocked

Rub between thumb and forefinger

Rotational rubbing, backwards and forwards with

clasped fingers of right hand in left palm and vice versa

Once dry your hands are safe.

Dr.T.V.Rao MD 61
http://www.who.int/gpsc/tools/GPSC-HandRub-Wash.pdfhttp://www.who.int/gpsc/tools/GPSC-HandRub-Wash.pdf


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HAND HYGIENE

The best method to prevent

healthcare acquired infections

including VAP is to practice goodHand Hygiene including use of :

Antimicrobial soap and water

Alcohol Based Hand Rub (Isagel)

when there is no visible soiling on

handsDr.T.V.Rao MD 62

Compliance with Isolation


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Precautions

Stringent adherence to the use ofPersonal Protective Equipment (PPE)such as Gowns, Masks, Gloves willdecrease the transmission ofpathogenic microorganisms toventilated patients when patients areidentified as requiring Contact andDroplet Precautions

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Dr.T.V.Rao MD 64

Why should hospitals care so


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much about the oral cavity ?

Most bacterial nosocomial pneumonia arecaused by aspiration of bacteria colonizing theoropharynx or upper GI tract of the patient.

Centres for Disease Control (1997)

Nosocomial pneumonia accounts for 10-15% ofall hospital acquired infections.

20-50% of all infected patients will die as aresult of the infectionJ.Can.Dent.Assoc.(2002)

How Does Aspiration Pneumonia


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How Does Aspiration Pneumonia

(including VAP) Occur?

ASPIRATION

+

GRAM - BACTERIA+

OVERWHELM

IMMUNE SYSTEM

MUST HAVE ALL 3

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When does Colonization occur?

Within 48 hours of admission to hospital the

oropharengeal flora of critically ill patients

changes from

the usual gram + streptococci and dentalpathogens to

gram organisms including Pathogens that

cause VAP and Aspiration Pneumonia

American Journal of Critical Care (2004)

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Oral Care Research

Treatment with oralhygiene alone,reduced occurrenceof pneumonia in

older adults innursing homes by30%

Yoneyama et.al. (2002)

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Oral decontamination

Chan et al. investigated antibiotics andantiseptics

Antibiotics were not found to be beneficial

Antiseptics were found to be beneficial in 6 out of7 studies

Chlorhexidine studied in 6, five of which showedbenefit

Note that mortality, ICU stay and duration ofmechanical ventilation were not statisticallysignificant

Dr.T.V.Rao MD 69


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Oral Cleansing

Bacteria in the mouthcan cause intubatedpatients to getinfections or

pneumonia.Establishing regular oralcleansing anddisinfection of patients

receiving respiratoryventilation reduces therisk of infection.

Dr.T.V.Rao MD 70

Current Oral Care


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Practices Continued

Foam swabs are commonly used to provide

mouth care to patients who cannot provide

their own care.

SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND

ONLY PROVIDE MOISTURE REFIEF.Journal of Advanced Nursing (1996)

Nursing Times (1996)

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much about the oral cavity ?

Most bacterial nosocomial pneumonia arecaused by aspiration of bacteria colonizing theoropharynx or upper GI tract of the patient.

Centres for Disease Control (1997)

Nosocomial pneumonia accounts for 10-15% of allhospital acquired infections.20-50% of all infected patients will die as a result of

the infection J.Can.Dent.Assoc.(2002)

Dr.T.V.Rao MD 72


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Oral Care

Common medical knowledge that poor oral

care and suctioning leads to (HAP) and (VAP).

Research has shown that (HAP) and (VAP) can

be reduced with suctioning of subglotticsecretions and improved oral hygiene in both

non-ventilated and ventilated patients.

Unfortunately some patients tend to bitedown and resist oral hygiene and tracheal

suctioning.

Dr.T.V.Rao MD 73

l


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Oral Care

Also tracheal suction catheters

commonly inserted nasally, tend to coil

upon insertion, causing multiple

unsuccessful attempts, nasal trauma and

bleeding. These problems make oral

hygiene and tracheal suctioning difficult

or even impossible, increasing a patients

risk to develop (HAP) and (VAP).

Dr.T.V.Rao MD 74

O l C AACN


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Oral Care: AACN

AACN 5th Edition, 2005 Scott JM, Vollman KM

Endotracheal Tube and Oral Care, Procedure # 4

Unit One Pulmonary System

Perform ET suctioning only when clinically indicated Oral hygiene should be performed every 2-4 hours and should

include:

Toothbrushing at least two times a day;

Oral swabs with 1.5% hydrogen peroxide solution every 2-4

hours; Mouth moisturizer to oral mucosa and lips

Subglottic suctioning continuously or intermittently

Dr.T.V.Rao MD 75

O l C l


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Oral Care: plaque

Grap MJ, Munro CL 2004:

Tooth brushing is the most effective means of

mechanical removal of plaque.

Munro CL, Grap MJ, Elswick RK, el al: 2006;AmJ CritCare;15

Higher plaque scores confer greater risk for VAP

Dr.T.V.Rao MD 76

P d B hi


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Procedure - Brushing

Wash hands and put on gloves

Obtain PLAC VAC BRUSH

Attach suction to toothbrush, moisten toothbrush and

apply baking soda Brush patients teeth, gums, tongue, palate and

inside cheeks

Apply suction to cleansed areas Rinse brush in water, repeat step 4-5

Soak dentures in denture solution

Dr.T.V.Rao MD 77

Alternate Procedure


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Alternate ProcedureChlorhexidine 0.12%

1. Place 15ml of chlorhexidine in medication

cup

2. Soak toothette in chlorhexidine

3. Rub teeth, tongue, gums, and sides of

mouth in circular motion

4. Suction oral cavity and do not rinse

5. Apply oral moisturizer to lips

Dr.T.V.Rao MD 78

O l C f i i


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Oral Care: use of antiseptics

Fourrier 2005 Crit Care Med 33

CHGreduced colonization but not VAP

Munro & Grap 2006 Crit Care Med 34

CHGeffective in reducing VAP

Seguin 2006 Crit Care Med 34

Povidone-Iodine - decreased prevalence of VAP in

head trauma

Dr.T.V.Rao MD 79

O l C


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Dr.T.V.Rao MD80

Oral Care Role of oral care, colonization of the

oropharynx, and VAP unclear dental plaque

may be involved as a reservoir

Limited research on impact of rigorous oral

care to alter VAP rates

Surveys indicate most nurses use foam swabs

rather than toothbrushes in intubated

patients

CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004

Grap M. Amer J of Critical Care 2003;12:113-119.


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E C


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Eye Care The unconscious, sedated or paralyzed patient

is at risk of developing eye problems rangingfrom mild conjunctivitis to serious cornealinjury and ulceration. Permanent eye damage

may result from ulceration, perforation,vascularization and scarring of the cornea

2nd hourly eye care using saline soaked gauzeto clean the eye and the application of

lactrilube regularly in the ventilated patient isrecommended to help reduce the risk ofcomplications

Dr.T.V.Rao MD 82

SDD- selective decontamination of the


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SDD selective decontamination of the

digestive tract

Multiple studies showing effectiveness

Big concern is antibiotic resistance

Most recently- NEJM January 2009

Study of 13 intensive care units inNetherlands showed statistically significantreduction of mortality of 3.5% in patients

receiving SDD Same study showed that patients receiving

SOD (selective oropharengealdecontamination) had decrease of 2.9%

Dr.T.V.Rao MD 83

Monitoring for infection


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Monitoring for infection

Color, consistency, and amount of

the sputum / secretions with each

suctioning should be observed. Fever and other parameters have to

closely observed for any other

infection. (central line, etc)

Dr.T.V.Rao MD 84

B t i l i St t


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Bacteriologic Strategy

Quantitative cultures can be performedon endotracheal aspirates or samplescollected either bronchoscopically or

nonbronchoscopically, and eachtechnique has its own diagnosticthreshold and methodologic limitations.

The choice of method depends on localexpertise, experience, availability, andcost (Level II)

Dr.T.V.Rao MD

C i Di ti St t


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Comparing Diagnostic Strategy

A patients with suspected VAP should have alower respiratory tract sample sent for culture,and extra pulmonary infection should be excluded,

as part of the evaluation before administration ofantibiotic therapy (Level II)

If there is a high pretest probability of pneumonia,or in the 10% of patients with evidence of sepsis,

prompt therapy is required, regardless of whetherbacteria are found on microscopic examination oflower respiratory tract samples (Level II)

Dr.T.V.Rao MD

I f t di ti t t


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Imperfect diagnostic tests

Blood cultures, limited role, sensitivity is only 8% to 20% Sputum neither sensitive, nor specific

Tracheo-bronchial aspirates- high sensitivity, weakness- does notdifferentiate between pathogen and colonizer

Hospital-acquired pneumonia: Risk factors, microbiology, and treatment. Chest. 119: 2001; 373S-384S.BAL, PSBs do not differ from less invasive tests in terms of sensitivity,

specificity or, more importantly, morbidity and mortality

luckof consensus on the role of invasive diagnostic testing for HAP,subject of ongoing debate

- Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia: Evaluation of outcome. Am J RespirCrit Care Med. 162: 2000; 119-125.

- Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia: A randomized trial. AnnIntern Med. 132: 2000; 621-630.

HCAP, HAP, VAP


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, ,

Treatment

Delay in empiric antibiotics use, worseoutcomeInternational conference for the development of consensus on the diagnosis andtreatment of ventilator-associated pneumonia. Chest. 120: 2001; 955-970.

Mortality with prompt antibiotic use 30%vs. 91 % when delayed Nosocomial pneumonia: A multivariate analysis ofrisk and prognosis. Chest. 93: 1988; 318-324

Regimens in patients with no known riskfactors for MDR pathogens, and who haveearly-onset pneumonia (within 5 days ofhospitalization) should include coverage forEnterobacterspp., E. coli, Klebsiella spp.,Proteus spp., and Serratia marcescens),Haemophilus influenza and Streptococcus

pneumoniae, MSS. aureus

HCAP, HAP, VAP


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, ,

Treatment

Ceftriaxone or a quinolone (e.g.,ciprofloxacin or levofloxacin) orampicillin-sulbactam or Ertapenem

Fluoroquinolone in the empirical regimenof patients with penicillin allergies

Penicillin skin testing a mean to

decrease fluoroquinolones use A pilot study of penicillin skin testing in patients with a history of penicillin allergy admitted to

a medical ICU. Chest. 118: 2000; 1106-1108.

Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia * in

Patients at Risk for Multidrug-Resistant Pathogens


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Patients at Risk for Multidrug Resistant Pathogens

Antibiotic Adult Dosage

Antipseudomonal cephalosporin

Cefepime 1-2 g every 8-12 hr

Ceftazidime 2 g every 8 hrCarbapenems

Imipenem 500 mg every 6 hr or 1 g every 8 hr

Meropenem 1 g every 8 hr

Beta-lactambeta-lactamase inhibitor

Piperacillin-tazobactam 4.5 g every 6 hr

AminoglycosidesGentamicin 7 mg/kg/day

Tobramycin 7 mg/kg/day

Amikacin 20 mg/kg/day

Antipseudomonal quinolones

Levofloxacin 750 mg/day

Ciprofloxacin 400 mg every 8 hr

Vancomycin 15 mg/kg every 12 hr

Linezolid 600 mg every 12 hr

Guidelines for the management of adults with hospital-acquired, ventilator-associated, and

healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416.

D ti f t t t


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Duration of treatment

No consensus, initial low suspicion, nochange in clinical status- dc in 72 hrs Short-courseempiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. A proposed solution forindiscriminate antibiotic prescription. Am J Respir Crit Care Med. 162: 2000; 505-511.

Guided by severity, time to clinicalresponse, and the pathogenic organism

Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcareassociated-pneumonia. Am J Respir Crit Care Med. 171: 2005; 388-416.

Treat for at least 72 hours after a clinical

response is achieved International conference for the development of consensus on the diagnosis and treatment of ventilator-

associated pneumonia. Chest. 120: 2001; 955-970.

Recommendations for Assessing Response to


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Recommendations for Assessing Response to

Treatment

-Modifications of empirical therapy should be based on results of microbiology

testing in conjunction with clinical parameters.

-Clinical improvement of HCAP usually takes 2 to 3 days and therefore therapy

should not be changed during this period unless there is a rapid clinical decline.

-Narrowing therapy to the most focused regimen possible on the basis of culture

data (de-escalation of antimicrobials) should be considered for the responding

patient.

-The nonresponding patient should be evaluated for possible MDR pathogens,extrapulmonary sites of infection, complications of pneumonia and its therapy, and

mimics of pneumonia.

-Testing should be directed to whichever of these causes is likely after physical

examination of the patient.

Prevention Measures


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Prevention Measures

Based on expert opinion rather than hard data CDC published a set of 74 recommendations for

preventing NAP , only 15 strongly supported by well-

designed experimental or epidemiologic studies

14 out of those 15 dealt with surveillance, education,

hand washing, sterilization, proper use of gloves,

value of vaccination, and sanitation

Prophylactic antibiotics not be used routinely , onlyone supported by well-designed studies

Centers for Disease Control and Prevention. Guidelines for prevention of nosocomial

pneumonia. MMWR Morb Mortal Wkly Rep. 46: 1997; 1-79.

Appropriate staffing levels in the


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pp p g

ICU

Inverse relationshipbetween the adequacy ofstaffing levels andduration of stay andsubsequent development

of VAP. Increased workloads for

RNs and RTs lead toreliance on less trainedpersonnel that may

result in lapses ininfection control

Kollef MH Crit Care Med2004:32(6)

Dr.T.V.Rao MD 94

No Data


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Dr.T.V.Rao MD

95

to Support These Strategies

Use of small bore versus large bore gastrictubes

Continuous versus bolus feeding

Gastric versus small intestine tubes

Closed versus open suctioning methods

Kinetic beds

CDC Guideline for Prevention of Healthcare Associated Pneumonias

2004

Things to Remember


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Things to Remember

HACP, HAP, VAP = BAD for the patient

Quantitative diagnostic microbiology-

controversial!

Cover likely bugs promptly

Know your local bugs

De-escalate, shorten duration of therapy

Specific regimen, combination therapy- no

proven benefits



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Precautions

Stringent adherence to the use ofPersonal Protective Equipment (PPE)such as Gowns, Masks, Gloves will

decrease the transmission ofpathogenic microorganisms toventilated patients when patients areidentified as requiring Contact andDroplet Precautions

Dr.T.V.Rao MD 97

Diagnosis and treatment of


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Objective 2

Objective 1

Avoid

overtreatment

without VAPImmediate

treatment of

patients with VAP

ventilator-associated pneumonia

Brave and Committed Nurses,


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Doctors Save Many Lives

Dr.T.V.Rao MD 99

With Thanks To Many


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With Thanks .. To Many

I am grateful forseveral references in

World Wide Web

particularly fromCentral Disease

Control Atlanta USA

for propagating theknowledge on a very

complex topic is

simple formatsDr.T.V.Rao MD 100

Visit me for Many Topics of


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Interest on Infectious Diseases

Dr.T.V.Rao MD 101


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Programme Created by Dr.T.V.Rao MD

for Medical and Paramedical

Professionals Working in the IntensiveCare Units

Email

[email protected]

Ventilator Associated Infections VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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