VAP ANISH

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

Hospital-Acquired Pneumonia (HAP) & Ventilator-Associated Pneumonia (VAP) Healthcare-associated pneumonia (HCAP) Dr. ANISH M. JOSHI ICU REGISTRAR CRITICAL CARE DEPARTMENT

Definitions : 

Definitions Healthcare-associated pneumonia (HCAP): Arises within 90 days of having been admitted to an acute care facility & pt. has resided 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 hospital admission Is not incubating at the time of admission Ventilator-associated pneumonia (VAP): Arises 48-72 hours or more after endotracheal intubation (American Thoracic Society/IDSA. Am J Respir Crit Care Med 2005;171:388-416)

HAP: Impact : 

HAP: Impact Accounts for ~15% of all nosocomial infections (2nd most common cause of NI’s after UTI’s) Extra days in the hospital: 4-9 days Average extra days in ICU: 4.3 days In mechanically ventilated patients, the incidence increases with duration of ventilation. Approximately half of all episodes of VAP occur within the first 4 days of mechanical ventilation. The risk is estimated to be 3%/day during the first 5 days of ventilation, 2%/day during Days 5 to 10 of ventilation, and 1%/day after this. Incidence

Hospital Location & Relative Frequency of HAP & VAP : 

Hospital Location & Relative Frequency of HAP & VAP HAP 14% ICU HAP 37.5% Non-ICU HAP 62.5% VAP 86% 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)

INCIDENCE OF NOSOCOMIAL INFECTIONS IN COMBINED MEDICAL-SURGICAL ICU’s : 

INCIDENCE OF NOSOCOMIAL INFECTIONS IN COMBINED MEDICAL-SURGICAL ICU’s 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)

Prevention : 

Prevention General -effective infective control measure staff education/hand wash/isolation -survelliance identify 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/RT Aspiration and feeding - PUP  450 - Semirecumbent position especially when feeding -Enteral Vs Parenteral Modulation Colonisation,antiseptic and antibiotic -SDD -may reduce VAP /not effective when MDR -Prior antibiotic-reduce HAP/if inf in presence of antibiotic suggest MDR -Oral Chlorhexidine M/W Other -Stress ulcer prophylaxis –Sucralfate Vs H2 Blocker -Transfusion – restricted/leuckocyte depleted - Glycemic control

Risk Factors : 

Risk Factors Prior antimicrobial therapy in preceding 90 days Current hospitalisation of >5 days High frequency of antibiotic resistance in the community or in the specific hospital unit Presence of risk factors for HCAP: Hospitalisation for >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 MDR pathogen Immunosuppressive disease and/or therapy

Pathogenesis of HAP/VAP : 

Pathogenesis of HAP/VAP

Pathogenesis of HAP/VAP : 

Pathogenesis of HAP/VAP

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Pathogenesis of VAP Endogenous and Exogenous Sources

Causative Pathogens : 

Causative Pathogens

Classification of HAP & VAP: Risk Stratification : 

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

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

Diagnosis of HAP : 

Diagnosis of HAP

Diagnosis of HAP/VAP : 

Diagnosis of HAP/VAP Chest infiltrate with atleast one clinical feature -fever -leukocytosis -purulent tracheal secretion Noninvasive/Clinical approach Vs. Invasive /Quantitative culture approach

Non-invasive/Clinical CPIS (Clinical Pulmonary Infection Score) : 

Non-invasive/Clinical CPIS (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 sensitive component is improvement in oxygenation

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Invasive /Quantitative culture More distal the sampling: More specific but less sensitive Lower the threshold for growth

Differential Diagnosis : 

Differential Diagnosis Pulmonary oedema Pulmonary Contusion & haemorrhage Pulmonary embolism Hypersensitivity pneumonitis ARDS

Initial Therapy of HAP/VAP : 

Initial Therapy of HAP/VAP

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Management strategies summary HAP, VAP or HCAP suspected Obtain lower respiratory tract (LRT) sample for culture (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 48–72 hours No Yes Cultures + Cultures – Cultures – Cultures + Adjust antibiotic therapy,search for other pathogens,complications, other diagnosisor other sites of infection Search for other pathogens,complications, other diagnosesor other sites of infection Consider stoppingantibiotics De-escalate antibiotics, if possible, treat selected patients for 7–8 days and re-assess ATS/IDSA Guidelines. Am J Respir Crit Care Med 2005;171:388–416

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Empiric antibiotic therapy ATS/IDSA Guidelines. Am J Respir Crit Care Med 2005;171:388–416

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Initial empiric therapy, no known risk factors for MDR pathogens, early onset and 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

Initial empiric therapy in patients with late onset or risk factors for MDR pathogens, and any disease severity : 

Initial empiric therapy in patients with late onset or risk factors for MDR pathogens, and any disease severity Cephalosporin OR Carbapenem OR β-lactam/β-lactamase inhibitor PLUS Fluoroquinolone OR Aminoglycoside PLUS Linezolid (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 negative –aminoglycoside,quinolone- prolong --beta lactam- no/short (except carbepenem) Beta lactam---frequent dosing Aminoglycoside,quinolone---single daily dose

Optimal antibiotic therapy : 

Optimal antibiotic therapy Shorten the duration from 14-21 days to 8 days unless the pathogen is not pseudomonas aeruginosa 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,recurrent infection,microbiological persistence --PSB -<103 cfu/ml,72 hours after starting antibiotic-- Radiological—limited value as improvement lag behind clinical detect deterioration-multilobar,increase filtrate >50% ,cavity develop,significant pleural effusion Clinical --core temp,WBC,oxygenation

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Deterioration or Nonresolution

CX : 

CX  length of stay in ICU/Hosp.  Expensive Necrotizing pneumonia with risk of pul. h’rrage Prolonged rehabilitation due to muscle loss particluarly in elderly Death

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THANKYOU

Risk Factors (contd.) : 

Risk Factors (contd.) (Mehta RM. J Intensive Care Med 2003;18:175-88) (Patel PJ, et al. Seminar Respir Crit Care Med 2002;23:415-25) (American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416)