ventilator assoc pneumonia1[1]

8/8/2019 Ventilator Assoc Pneumonia1[1]

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Ventilator AssociatedVentilator AssociatedPneumoniaPneumonia

Dr Sumant MantriDr Sumant Mantri

ConsultantConsultant -- Pulmonary, Critical CarePulmonary, Critical Careand Sleep Medicine,and Sleep Medicine,

Apollo Hospitals, BangaloreApollo Hospitals, Bangalore


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IntroductionIntroduction

Nosocomial PneumoniaNosocomial Pneumonia--22ndnd most commonmost commonnosocomial infectionnosocomial infection

Affects 27% of critically ill patientsAffects 27% of critically ill patients

86% are Ventilator Associated Pneumonia86% are Ventilator Associated Pneumonia ApproxApprox-- 2 to 3 Lakh per year2 to 3 Lakh per year

Mortality in the range of up to 50%Mortality in the range of up to 50%

Higher mortality is seen with multi drug resistantHigher mortality is seen with multi drug resistantorganisms like Pseudomonas, Acinetobactar andorganisms like Pseudomonas, Acinetobactar and

StenotrophomonasStenotrophomonas Increases length of ICU stay by 4Increases length of ICU stay by 4--13 days13 days

Increase in cost of AntibioticsIncrease in cost of Antibiotics


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Nosocomial PneumoniaNosocomial Pneumonia

Infection of Lung Parenchyma that is neitherInfection of Lung Parenchyma that is neither

present nor incubating at the time of hospitalpresent nor incubating at the time of hospitaladmission.admission.

Healthcare Associated Pneumonias (HCAP) newHealthcare Associated Pneumonias (HCAP) newentity for patients from chronic care facility or withentity for patients from chronic care facility or withrecent hospitalization.recent hospitalization.


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Ventilator Associated Pneumonia (VAP)Ventilator Associated Pneumonia (VAP)

Defined as Pneumonia occurring more than 48Defined as Pneumonia occurring more than 48

hours after patient having been intubated andhours after patient having been intubated andreceiving mechanical ventilation.receiving mechanical ventilation.

Diagnosing VAP requires high clinical suspicionDiagnosing VAP requires high clinical suspicioncombined with bed side examination,combined with bed side examination,radiographic examination and microbiologicalradiographic examination and microbiological

analysis of respiratory secretions.analysis of respiratory secretions.


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Risk Factors for VAPRisk Factors for VAP

Age more than 60 yearsAge more than 60 years

COPD/ Pulmonary diseaseCOPD/ Pulmonary disease

Coma/ Impaired consciousnessComa/ Impaired consciousness

Therapeutic interventionsTherapeutic interventions

Organ failureOrgan failure

Large volume gastric aspirationLarge volume gastric aspiration Prior antibioticsPrior antibiotics

H2 Blockers +/H2 Blockers +/-- antacidsantacids

Gastric colonization and PhGastric colonization and Ph

Ventilator circuit change 24 versus 48hVentilator circuit change 24 versus 48h ReRe--intubationintubation

TracheostomyTracheostomy

Supine head positionSupine head position


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Risk Factor for Mortality in Patients with VAPRisk Factor for Mortality in Patients with VAP

Aerobic gramAerobic gram--negative Bacilli e.g Pseudomonasnegative Bacilli e.g Pseudomonasand Acinobactarand Acinobactar

Severity of underlying illnessSeverity of underlying illness

Inappropriate antibiotic therapyInappropriate antibiotic therapy

Advanced AgeAdvanced Age

ShockShock

Bilateral infiltratesBilateral infiltrates

Prior antibiotic usePrior antibiotic use Duration of hospitalizationDuration of hospitalization


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Diagnosis of VAPDiagnosis of VAP

New and persistent (> 48 hrs) infiltrates on chestNew and persistent (> 48 hrs) infiltrates on chestradiographradiograph

Plus 2 or more of the following:Plus 2 or more of the following:

Fever > 38.3Fever > 38.3ooC or < 36C or < 36ooCC

Leucocytosis > 11000 mmLeucocytosis > 11000 mm33

or < 4000 mmor < 4000 mm33

Purulent tracheobronchial secretionsPurulent tracheobronchial secretions

Gas exchange degradationGas exchange degradation

Sensitivity of 69%, Specificity of 75%Sensitivity of 69%, Specificity of 75%

Clinical suspicion should be high in case of ARDSClinical suspicion should be high in case of ARDS

if one criteria with hemodynamic unif one criteria with hemodynamic un--stability or unstability or unexplained deterioration in ABGexplained deterioration in ABG


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Differential DiagnosisDifferential Diagnosis

Nosocomial tracheobronchitisNosocomial tracheobronchitis-- Purulent secretionsPurulent secretionswith positive culture and fever, Leucocytosiswith positive culture and fever, Leucocytosiswithout chest infiltrateswithout chest infiltrates

Congestive Cardiac FailureCongestive Cardiac Failure

DVTDVT

Pulmonary EmbolismPulmonary Embolism Chemical AspirationChemical Aspiration

ARDSARDS

AtelectasisAtelectasis

Infection elsewhereInfection elsewhere Drug FeverDrug Fever


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Clinical Pulmonary Infection Score (CPIS)Clinical Pulmonary Infection Score (CPIS)Pugin et alPugin et al

TemperatureTemperature

WBC CountWBC Count SecretionsSecretions

PaOPaO22/ FiO/ FiO22 Chest XChest X--rayray

Semi quantative culture of Tracheal AspirateSemi quantative culture of Tracheal Aspirate

Score 0Score 0 1212> 6> 6 SignificantSignificantSensitivity 93% and Specificity 100%Sensitivity 93% and Specificity 100%DrawbackDrawback-- small number of patientssmall number of patients


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Quantitative culture of Airway SpecimenQuantitative culture of Airway Specimen

To improve specificity of diagnosis of VAP and reduceTo improve specificity of diagnosis of VAP and reduceunnecessary antibiotic use and associated problemsunnecessary antibiotic use and associated problems

QEAQEA-- Quantitative culture of Endotracheal aspirateQuantitative culture of Endotracheal aspirate--

> 10> 1066

CFU/ml Sensitivity 76CFU/ml Sensitivity 76

PSBPSB-- Protected Specimen BrushingProtected Specimen Brushing-- > 10> 1033 CFU/mlCFU/mlSensitivity 89% and Specificity 94%Sensitivity 89% and Specificity 94%

BALBAL-- > 10> 1044 CFU/ml Sensitivity 73% Specificity 82%CFU/ml Sensitivity 73% Specificity 82%


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Common PathogensCommon Pathogens

Early onsetEarly onset-- S Pneumoniae, H InfluenzaeS Pneumoniae, H Influenzae

Late onsetLate onset Pseudomonas, Enterobacter spp,Pseudomonas, Enterobacter spp,Acinetobactar, Klebsiella, E. Coli, S.aureusAcinetobactar, Klebsiella, E. Coli, S.aureus


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TreatmentsTreatments

Based on present local resistance patternBased on present local resistance pattern

Rational Antibiotic regimeRational Antibiotic regime

DeDe--escalation or stoppage after sensitivity report.escalation or stoppage after sensitivity report.

Delay in treatment by 24 hrs increases mortality byDelay in treatment by 24 hrs increases mortality by60%60%


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Mild to Moderate SeverityMild to Moderate Severity-- No risk factorsNo risk factorsOnsetOnset-- Anytime and severe infection with early onsetAnytime and severe infection with early onset

Core OrganismsCore Organisms Core AntibioticsCore Antibiotics

Enteric gram NegativeEnteric gram NegativeBacilli(Non Pseudomonas)Bacilli(Non Pseudomonas)

Pip + Tazo orPip + Tazo or

Enterobacter sppEnterobacter spp Cefotaxime or Cefotaxime or

E colliE colli Ceftriaxone or Ceftriaxone or

KlebsiellaKlebsiella If allergic toIf allergic to

Penicillins/CephalosporinsClindPenicillins/CephalosporinsClindamycin or Vancomycin +amycin or Vancomycin +Ciprofloxacin orCiprofloxacin or

H Influenzae, MSSAH Influenzae, MSSA AztreonamAztreonam


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Mild to Moderate Infection with risk factorsMild to Moderate Infection with risk factorsOnsetOnset-- AnytimeAnytime


AnaerobesAnaerobes Pip + Tazo or ClindamycinPip + Tazo or Clindamycin

Staph. AureusStaph. Aureus Vancomycin or LinezolidVancomycin or Linezolid

LeggionellaLeggionella FluoroquinoloneFluoroquinolone


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evere n ec onevere n ec on


PseudomonasPseudomonas Pip + Tazo or Pip + Tazo or

AminoglycosideAminoglycosideAcinetobactarAcinetobactar Flouroquinolone + one of theFlouroquinolone + one of the

followingfollowing-- Pip + Tazo orPip + Tazo or

CarbapenemsCarbapenems

MRSAMRSA Vancomycin or LinezolidVancomycin or Linezolid


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PreventionPrevention

Prior to IntubationPrior to Intubation-- Address reversible causes of respiratory failureAddress reversible causes of respiratory failure

NIVNIV

Process of IntubationProcess of Intubation-- Avoid Gastric over distentionAvoid Gastric over distentionOral intubationOral intubation

After intubationAfter intubation-- N.G. tube inseted visa ora; routeN.G. tube inseted visa ora; route

(Data supported)(Data supported) Elevated head end by 30 to 45Elevated head end by 30 to 45ooGood hand hygieneGood hand hygiene

HME use when appropriateHME use when appropriateChange respiratory circuit when necessaryChange respiratory circuit when necessary

Good respiratory care hygieneGood respiratory care hygieneClosed suction systemClosed suction system

Continuous subglottic suctioningContinuous subglottic suctioningRotational bedsRotational beds

Chlorhexidine oral rinse in cardiac surgeryChlorhexidine oral rinse in cardiac surgerypatientspatients

Minimise sedationMinimise sedationWeaning protocolsWeaning protocols


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After intubationAfter intubation-- Early vs Late enteral feedsEarly vs Late enteral feeds

(controversial)(controversial) Selective gut decontaminationSelective gut decontamination

Rotational Antibiotic PolicyRotational Antibiotic Policy

Antibiotic impregnated endo tracheal tubesAntibiotic impregnated endo tracheal tubes

(contd)(contd)


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ConclusionConclusion

Low threshold for suspicion of VAP when clinicalLow threshold for suspicion of VAP when clinicaldeterioratesdeteriorates

CPIS core may be useful if combined withCPIS core may be useful if combined withquantitative culturesquantitative cultures

Antibiotics should be promptly initiatedAntibiotics should be promptly initiated

De escalation as soon as possibleDe escalation as soon as possible

Simple and effective preventive measures can beSimple and effective preventive measures can beinstituted easily with minimal costinstituted easily with minimal cost


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Thank You!!Thank You!!

ventilator assoc pneumonia1[1]

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