nosocomial pneumonia hospital acquired, ventilator associated, healthcare associated pneumonia
TRANSCRIPT
Outline and Goals
• Learn Definitions of types of NP
• Learn Pathogenesis/Epidemiology
• Learn Diagnosis
• Learn Initial Management
• Learn Impact of NP
• Learn Prevention of NP
Hospital Acquired Pneumonia
• “occurs 48 hours or more after admission”
•“was not incubating at the time of admission”
• Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia
•American Thoracic Society and the Infectious Diseases Society of America•Am J Respir Crit Care Med Vol 171. pp 388–416, 2005
Ventilator Associated Pneumonia
• > 48 to 72 hours on closed ventilator
• Non-Invasive Ventilation not a factor
Healthcare-Associated Pneumonia
• Nursing Home/LTCH resident
• >48Hr hospital stay in past 90 days
• Within past 30 days had:
• Wound Care or I.V. Therapy
• HD or Hospital Clinic visit
Colonization LRT
• Microaspiration
• Introduction by devices (catheters, aerosolized material)
• Direct Leakage around ETT cuff
• Biofilm
Vulnerable Host Defenses
• Cellular/Humoral Defenses
‣ Immunosupressed, infected, surgery, organ failure, recent antibiotics, frequent transfusions of blood/blood products
• Mechanical Defenses
‣ Turbinates, vocal chords, ciliated epithelium, cough, acidified stomach
VAP Incidence
• 90% of the HAP in the ICU is VAP
• Incidence increases over time but risk highest early in vent course
• 3%/day from day 0 to 5, 2%/day from day 5-10, 1%/day after
• So risk starts at minute zero of intubation
Microbiology
• Frequently polymicrobial
• Multidrug Resistance (MDR) Problem
• Similar spectrum in all types NP
• Viral/Fungus very uncommon
Aerobic Gram Negatives
• Pseudomonas
• Klebsiella
• Acinetobacter
• Very Institution Specific
• Stenotrophomonas
• Legionella
Risk for MDR
• HCAP risks
• >5 days since admission
• Antibiotics in past 90 days
• Immunosupressed
• High MDR rate in hosp/unit
Suspect Pneumonia if:
• New/Progressive CXR findings
• Clinical Infection Findings
• Fever, Leukocytosis, Leukopenia
• Respiratory Findings
• Purulent Sputum, Deoxygenation
Additional Clinical Clues
• Mental Status Change in Elderly
• New Crackles, Egophony
• Worsening Dyspnea or Cough
• Increased Need for Vent Support
• Increased Suction Requirements
Diagnosis: Cultures
• Sensitivity and specificity poor with clinical criteria alone
•especially with vented patients
• CXR+ and 2/3 clinical findings present
•sensitivity 69%
•specificity 75%
•Fabregas et al, Thorax 1999;54:867–873
Lower Respiratory Cx
• Bronchoscopy or ETT Aspiration
• Both good NPV (>90%)
• ETT aspirate can’t distinguish colonizers; may lead unnecessary abx
• Bronch invasive; not as accessible
Blood Cultures
•Always obtain
•Limited sensitivity (25%)*
•May be extrapulmonary so limited specificity*
•For non-vented patients may be only accessible culture
• *Luna CM et al, Chest 1999;116:1075
Microbiological Diagnosis
• Culture if clinically suspect NP, BEFORE antibiotics if possible
• Always try LRT Cx or Sputum
• Always blood culture
• Avoid unnecessary sampling to prevent unneeded abx and MDR
Initial Management
• Empiric early therapy with APPROPRIATE antibiotics
• Do not delay therapy for microbiological sampling
• Delay in therapy has higher mortality
Appropriate Antibiotics?
• HAP with no MDR risks?
• Becoming less common, but can use
• Ceftriaxone
• Ampicillin/sulbactam
• Moxifloxacin
Appropriate Antibiotics
• Otherwise should start with
• Antipseudomonal therapy
• Cefepime, Imipenem, Meropenem
• plus
• MRSA Therapy
• Vancomycin, Linezolid
Impact of HAP/VAP
• 25% ICU infections HAP
• Most common cause for antibiotic use in ICU - likely contributor to MDR
• HAP extends LOS by 7-10 days
• Mortality ranges 30 - 70%
• Cost of one case $40,000
Prevention
•We give patients this.
•The chief complaint on entering the health care system is never:
•“I have ventilator associated pneumonia”
•Everyone who touches the patient has a responsibility to prevent it.
Hand Washing
• Before and after every patient contact however small
• Dirty hands are lethal weapons
• Soap/Water 30 seconds
•(“Happy Birthday” or “ABC” twice)
• Alcohol Scrub acceptable
Circuit Integrity
• The ventilator tubing (called “circuitry”) is changed weekly
• More frequent changes do not reduce VAP
• Avoid opening it unnecessarily - use in-line suction catheter if possible
Patient Positioning
•Elevate Head of Bed (HOB) to 30-45˚
•Reduces clinical rate from 34% to 8%*
•Reduces culture rate from 23% to 5% *
•Every vented patient should have HOB >30˚at all times from the start unless absolute contraindication
• Lancet 1999 Nov 27;354:1851
Judicious Intubation
• Cannot get VAP if not on the Vent
• NIPPV good for CHF, COPD
• Not good for AMS, Secretions
• Do not delay necessary intubations
Removal of Ventilator
• Cannot get VAP if not on the Vent
• Patients need aggressive weaning
• Includes daily waking from sedation
• Includes daily wean trials if meets criteria (see weaning protocol)
IHI Bundle
1.HOB Elevation
2.Daily Sedation Vacation
3.Daily Wean Trials
4.DVT Prophylaxis
5.GI Ulcer Prophylaxis
• Some institutions self-report VAP rates of 0% after adopting IHI bundle
• Only 3/5 recommendations directly impact VAP
• HAP/VAP/HCAP significant cause of hospital/ICU Morbidity
• Significant cost in resources, patient safety and likely mortality
• Significant public health problem; possibly fueling development of MDR
Summary
Summary
• Once suspect diagnosis must attempt to confirm with cultures
• Empiric antibiotics must be started quickly
• Coverage for MRSA and Pseudomonas in most cases is warranted
Summary
• Rapid de-escalation of antibiotics
• Narrow if pathogen known
• Remove if improves and cultures negative