who | cataldo adriana presentation

Multimodal approaches for ventilator-associated pneumonia

Maria Adriana Cataldo

National Institute for Infectious Diseases “L. Spallanzani”, Rome

30 November - 2 December 2011, Rome, Italy

HD# 5

- severe CODP exacerbation

- presence of risk factors for P. aeruginosa

started pip/tazo + gentamycin

HD#7

- BAL grew P. aeruginosa susceptible to quinolones and anti-

pseudomonal beta-lactams

- Improvement of hypoxia

AT was not changed

HCWs decided to evaluate possibility of weaning the day after

Patient to nurse ratio: 3 to 1

New nurses with little experience

HH measures compliance not recently checked

No recent educational meeting on VAP prevention

No constant semirecumbent position

No regular oral care with antiseptic

No selective digestive decontamination

HD#9MV day 4Severe hypoxiaNew chest X rayDiagnosis of VAP

VAP is due to several factors:

tubes

aspiration of the nasal and oropharyngeal secretions

underlying morbidity and impairment of host defenses

active surveillance for VAP

adhere to hand-hygiene guidelines

use noninvasive ventilation whenever possible

minimize the duration of ventilation

daily assessments of readiness to wean and use of weaning

protocols

educate HCWs about VAP

semirecumbent position (30-45 elevation of the head of the bed)

avoid gastric overdistention

avoid unplanned extubation and reintubation

perform subglottic secretion drainage

orotracheal instead of nasotracheal intubation

regular oral care with an antiseptic solution

use sterile water to rinse reusable respiratory equipment

remove condensate from ventilatory circuits.

keep the ventilatory circuit closed during condensate removal

change the ventilatory circuit only when visibly soiled or

malfunctioning.

store and disinfect respiratory therapy equipment properly

No clear recommendation in GL

Use still controversial

non-absorbable oral antibiotics (polymyxin, tobramycin and

amphotericin B) topically to the oropharynge and stomach

intravenous administration of cefotaxime

Several meta-analyses: efficacy in decreasing the VAP rate and

mortality

Cochrane review: combination of topical and systemic prophylactic

antibiotics reduces respiratory tract infections and overall mortality

Use of topical prophylaxis alone reduced respiratory infections but

not mortality

- Kollef MH et al, Chest 1994;- Hurley JC, Antimicrob Agents Chemother 1995- D’Amico R et al, BMJ 1998- Nathens AB et al, Arch Surg 1999- Van Nieuwenhoven CA et al, JAMA 2001- Liberati A et al, Cochrane Database Syst Rev 2004

Its use not generalised worldwide: concern antibiotic development

Most experts recommendations still cautious

SHEA/IDSA GL: unresolved issue

European experts panel: routine use should be discouraged

UK GL: should be considered where it is anticipated MV≥ 48h

Meta-analysis: SDD led to trends towards colonization with Gram-

positive and pneumonia due to resistant Gram-negative

Cochrane review: no evidence of generalized emergence of

resistance, only isolated reports.

UK GL: absence of evidence that use of SDD results in emergence

and generalized spread of resistance

- Kollef MH et al, Chest 1994- Liberati A et al. Cochrane Database Syst Rev 2004

Open-label, clustered group-randomised, crossover study 13 ICUs Netherlands -SOD (topical tobramycin, colistin, and amphotericin B in the oropharynx)-SDD (SOD antibiotics in the oropharynx and stomach plus 4 days’intravenous cefotaxime)- standard careOutcomes: rate of acquired bacteraemia and respiratory tract colonization by AR bacteriaSDD vs standard care: lower rate of bacteraemia and respiratory tract colonization SOD vs standard care: lower rate of respiratory tract colonisation

Kaplan-Meier analysis of time to event of acquisition of cefotaxime-resistant Enterobacteriaceae

IV cefotaxime vs standard care and SOD: lower rate of cefotaxime-resistant Enterobacteriaceae in the respiratory tract

Extended use of SDD and SOD justified in settings with low rates of

antibiotic resistance.

The long-term effects on development of resistance should be

monitored

No available evidence on the best drug and doses

UK GL:

- include topical and parenteral agents anti-Gram-negative,

- drug choice depend on local antimicrobial susceptibility profiles

Duration of administration: SDD throughout the ICU stay, with the

systemic element for 3–4 days only

Some studies: protective effect on early VAP

Other showed higher risk of VAP

Meta-analysis 8 RCTs: aerosolised aa decreased VAP rate, no effect on

mortality.

Double-blind RCT: no lower incidence of VAP in the treatment group

- Sirvert JM et al, Am J Respir Crit Care Med 1997- Rello J et al, Am J Respir Crit Care Med 1999- Trouillet JL et al, Am J Respir Crit Care Med 1998- Ewig S et al Am J Respir Crit Care Med 1999- Claridge JA et al, Surg Infect (Larchmt) 2007

Canadian guidelines: no recommendation

SHEA/IDSA: not recommended routinely use

UK GL: systemic antibiotic prophylaxis only as part of SDD

Recently the awareness of the need for a multifaceted

approach has been increasing

Institute for Healthcare Improvement 5-component bundle:

◦ Elevation of the head of the bed

◦ Daily sedation vacations and assessment of readiness to extubate

◦ Peptic ulcer disease prophylaxis

◦ Deep venous thrombosis prophylaxis

◦ Daily oral care with chlorexidine

Several reports of success using this bundle

Certain recommended interventions not strongly supported by

evidence

Not all directly target VAP

New care bundle based on interventions discussed in European GL

Multicriteria decision analysis was used with a process of “weighting

and scoring”

Enforcement: daily infection control rounds with compliance assessment

pre-VAP bundle: 5.2 VAP/1,000 ventilation days

VAP bundle implementation: 2.4/1,000 days (NS)

VAP bundle enforcement: 1.2/1,000 days (NS)

including all trauma patients : significant decrease of VAP rate in

the enforcement period, but not in the implementation period

Necessity for strict compliance

Most recently published studies: emphasis on compliance

assessment and education

Educational program to improve prevention, reminders and compliance

assessment

8 preventive measures

1) HH with alcohol-based hand sanitizer

2) Gloves and gowns

3) Semirecumbent position

4) Endotracheal cuff pressure>20 cm H2O

5) Orogastric tube

6) Avoiding gastric overdistension

7) Mouth decontamination with chlorexidine at least 4 times/day

8) Avoiding nonessential tracheal suction

Other measures included

changing heat and moisture exchangers every 7 days or when

visibly soiled

keeping the same ventilator circuit in a given patient unless visibly

soiled or malfunctioning.

no continuous subglottic secretion aspiration or closed endotracheal

suctioning system

no SDD routinely

no stress ulcer prophylaxis routinely

standardized weaning protocol

Comparison VAP rates

Baseline period (45 months) before introduction multimodal strategy

Intervention period (30 months)

Significant improvement of compliance:

hand hygiene and glove-gown use: 68% and 80%, and stable over

time

keeping patients in the semirecumbent position: 5%–58%

maintaining an endotracheal tube cuff pressure: 40%–89%

using an orogastric tube: 52%–96%

avoiding gastric overdistension: 20%–68%

oral decontamination: 47%–90%

no use of nonessential tracheal suction: 41%–92%

Bouadma et al, Crit Care Med 2010

Before the intervention, VAP incidence density showed a nonsignificant increase over time (p.11). The intervention was associated with a significant decrease in VAP incidence rates (p.001).

Cox proportional hazard model:

Intervention decreased the VAP

incidence rate by 43% (HR, 0.57)

Multifaceted intervention to increase adherence to 5 preventive

measures:

1. semirecumbent positioning

2. stress ulcer prophylaxis

3. deep venous thrombosis prophylaxis

4. adjustment of sedation

5. daily assessment of readiness to extubate

Baseline data vs post-implementation (30 months)

Compliance with the 5 measures increased during the study period

VAP rate significantly decreased

- 5.5 cases/1,000 ventilator-days at baseline

- 0 cases at 18 months and at 30 months after implementation (P < .001)

Overall 71% reduction in VAP rate

Effectiveness of multimodal strategies for the prevention of VAP

Some shortcomings:

- methodological flaws in design, reporting and results of the

studies

- the various VAP prevention bundles proposed different

combination and number of interventions

- no consensus on the best combination

- concern on applicability in daily practice

Importance of the 100% compliance with the prevention measures

Non-completion of a single intervention equates to failure of the

whole bundle

Best implementation tailored to the local situation

Simple measures that can be monitored

Formulated into a simple document

Unmodifiable risk factorsDiabetesCODPOld age

Risk factors which would had been modified in the remote pastExposure to several antibioticsSeveral hospitalizations

Risk factors which would had been modified in the recent pastExposure to antibiotics High likelihood of aspirationHigh likelihood of colonization of the aerodigestive tract with AR Gram-negative bacteria

De-escalation of AT after 48 h

Constant semirecumbent position

Daily assessment of readiness to extubate

Regular oral care

Adherence to hand-hygiene measures and contact precaution

Active screening for colonization by MDR-bacteria

Nurses workload

Little experience

Decreased attention to HCWs education

No clear knowledge of the prevention measures

Written policy for VAP prevention

Regular education meetings

Regular assessment of compliance

Feedback to HCWs

Inconsistent evaluation of the possibility of extubation

Applicability of semirecumbent position in daily practice largely criticised

Frequent low compliance with hand-hygiene measures among HCWs

Low adherence to antimicrobial stewardship principles worldwide

Low full compliance with VAP bundles

Compliance with individual elements: no impact on VAP rate

Several surveys: lack of knowledge about VAP prevention

Simple distribution of guidelines is insufficient to change physician behaviour

Does this happen in real life?Does this happen in real life?

Systematic review of interventions to reduce HAIsSystematic review of interventions to reduce HAIs

With current evidenceWith current evidence--based strategies may be preventable:based strategies may be preventable:

-- 6565--70% of cases of catheter70% of cases of catheter--associated BSI and UTIassociated BSI and UTI

-- 55% of cases of VAP and SSI 55% of cases of VAP and SSI

Highest number of preventable deaths: CABSI followed by VAPHighest number of preventable deaths: CABSI followed by VAP