ventilator associated pneumonia dilemmas in diagnosis & treatment ram e. rajagopalan, mbbs, ab...
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Ventilator Associated Pneumonia Dilemmas in Diagnosis & Treatment
Ventilator Associated Pneumonia Dilemmas in Diagnosis & Treatment
Ram E. Rajagopalan,MBBS, AB (Int Med) AB (Crit Care)
Department of Critical Care Medicine
SUNDARAM MEDICAL FOUNDATIONChennai
Goals of the Talk
Basic epidemiological concernsWhy is diagnosis difficult?Methods of diagnosis & controversies Principles of Rx & concerns__________________________________________________________________
Not A discussion of risk factors for VAP or prevention
Definition of VAP**Ventilator Associated Pneumonia:Bacterial pneumonia developing de-novo in a patient who has received mechanical ventilation for at least 48 hours
Intubation for mechanical ventilation increases the risk for pneumonia 3x to 21x !AJRCCM 2002; 165:867-903
Incidence of VAPWorldwide: <20 / 1000 ventilator days
0
5
10
15
20
25
30
Inci
den
ce (
%)
1 2 4 6 8 10 12 14
Ventilator Days
VAP Incidence
Clinical averages: All ~9%Med ICU ~17%Med/ Surg ICU ~9%
Developing Nation ICUs
24.1 cases /1000 ventilator days
4x as frequent as in the US NNIS
AJRCCM 2002; 165: 867-903Ann Int Med 2006; 145: 582-91
SMF (CDC Definition): 3-month survey
VAP / Patients ventilated (%) = 23.4%(13-37)VAP / 1000 ventilator days = 27.5 (CI; 14-48)
International Nosocomial Infection Control Consortium (INICC)
Developing Nation ICUs(International Nosocomial Infection Control Consortium)
Ventilator Associated Pneumonia:
INICCPs. Aeruginosa: 24% Ps. Aeruginosa: 26%Staph Aureus: 20% Enteric Gm neg: 26%Enteric Gm neg: 14% Staph Aureus: 22%Strep Species: 12% Acinetobacter: 20%AJRCCM 2002; 165: 867-903
Ann Int Med 2006; 145: 582-91
Diagnosis: Which Gold Standard?Histopathology (post-mortem; full lung)
Histopathology (open lung biopsy)
Microbiology (lung aspirate)Microbiology (distal bronchial sample)
Microbiology (proximal airway)
Clinical
Too rigid ?
Too lax ?
JAMA. 2007;297:1583-1593
Likelihood Ratiosand probability ofdisease
Clinical Diagnosis
AJRCCM 2003; 168: 173-79
When clinicians are asked to “judge”the probability of VAP each individualgives different “weights” to clinical findings
In a study of clinical diagnosis Sensitivity = 50 / Specificity = 49 No difference between trainees &
experienced clinicians
Radiographic FindingsAlveolar infiltrate
Air bronchogram
Silhouette
AtelectasisFissure-abutment
Radiology
Clinical signs alone or in combo have no predictive value
New InfiltrateLR + 1.7 (posterior ~35%)
Air BronchogramLR +3.8 (posterior = ~50%)
Problems with Dx of VAP
Clinical DefinitionInfiltrate +Fever (or)Leukocytosis (or)Purulent sputum
Chest 1996; 110:1025-34AJRCCM 2002; 165: 867-903
Pulmonary edemaARDS, Atelectasis, Contusion
Thromboemboli, Effusion
No feature has >65%predictive accuracy
Non-specific;Many infectious &
non-infectious aetiologies
Tracheo-bronchitisReactive airways
Onlysome
will have VAP
Clinical +RadiologyNew InfiltrateLR + 1.7 (posterior ~35%)
X-Ray finding + >2 clinical featuresLR +2.8 (posterior ~45%)
Improving Clinical DiagnosisClinical Pulmonary Infection Score
Temperature (0-2)WBC Count (0-1)PaO2/FiO2 (0-2)Chest X-ray (0-2) Quality of tracheal secretions (0-2)Progression of infiltrate (0-2) Culture of aspirate (0-2)
Overall fair inter-rater agreement k =0.5
Poor with subjective parameters k =0.2
CPIS
CPIS >6LR +2.1 (posterior = ~40%)
CPIS <6 (in suspected VAP)LR-ve 0.08 (posterior =<1%)
Laboratory Diagnosis
Gram stain of tracheal aspirates: Mod sensitivity (82%) & Very low specificity (27%)
Gram stain of BAL fluid / distal airway specimens 51% full agreement with PSB cultures
39% partial concordanceChastre & FagonAJRCCM 2002; 165: 867-903.
Obtaining Micro Specimens
Bronchoscopy “Blind”
Broncho-alveolarlavage(BAL)
Need volume >140 cc
ProtectedSpecimen Brush
(PSB)
Small sample
BAL PluggedTelescoping
CatheterUndirectedsampling
Organisms on Gram StainBronchial Aspirate LR + 2.1
Mini BALLR + 5.3 (Posterior ~60%)
BALLR + 18 (posterior ~80%)
< 50% Neutrophils has goodLR- 0.05 (Posterior~1.5%)
Microbiological Culture
Prob
abili
ty
1 2 3 4 5 6
VAP
Log CFUs
No VAP
CCM 2003; 31: 2544 – 51.
Routine culture of sputumDoes not differentiate infection vs. colonization
Microbiological Culture
PSB BAL(103) (104)
Sens ~90 ~80Spec ~95 ~85
Endo-tracheal Aspiration:“Qualitative EA analysis is of little valueEA with quantitative limits (105) is betterPoorer than distal bronchial cultures”
Distal specimens Bronchoscopic sampling idealBlind (non-bronchoscopy) may miss site(poorer sensitivity & specificity)
Chastre & FagonAJRCCM 2002; 165: 867-903.
CultureAlways post-hoc; should have good LR-ve too
Tracheal AspirateLR + 9.6 (Posterior ~ 70%)LR – 0.42 (Posterior ~15%)
BALLR +1.8 (posterior ~35%)LR – 0.8 (posterior ~20%)
Pre-culture DiagnosisElastin fibres (in KOH prep): Sensitivity 52%, Specificity 100% in non-ARDS
Intracellular Organisms; >5% of BAL cells(LR + 6.8)
TriggeringReceptorExpressed onMyeloid cells(TREM-1)
AJRCCM 2002; 165: 867-903.AJRCCM 2002; 166:1320–25NEJM 2004; 350: 451-8.
Which is the Best Test?1. No methodology “proves” VAP with
sufficient accuracy.
2. Only CPIS <6 and <50% neutrophils on BAL have ability to R/O
3. Gram stains of deep airway secretions are better than bronchial specimens
4. BAL cultures do not add significant value to diagnosisAJRCCM 2002; 166:1320–25
Options for the Rx of VAP
Bacteriologicallyconfirmed
Empirical Rx
Directed Rx
Clinicallysuspectedinfection
Attributable mortalityBenefit of early RxMinimal adverse effects
Developing Nation ICUs(International Nosocomial Infection Control Consortium)
Ventilator Associated Pneumonia:
INICCPs. Aeruginosa: 24% Ps. Aeruginosa: 26%Staph Aureus: 20% Enteric Gm neg: 26%Enteric Gm neg: 14% Staph Aureus: 22%Strep Species: 12% Acinetobacter: 20%AJRCCM 2002; 165: 867-903
Ann Int Med 2006; 145: 582-91
“De-escalation”
Chest 2002; 122:2183–2196.
De-escalate Rx
Lab confirmed
Initial Rxwide-spectrum
Suspectinfection
Culture-basedde-escalation can reduce resistance
Duration of RxRCT in 402 VAP cases; 8 days Rx (n=197) vs. 15 days Rx (n=205)
010203040506070
%
8-day
15-day
*
*
*
JAMA 2003; 290: 2588-98
Duration of Treatment
JAMA 2003; 290: 258-98 D = 15.2% (95% CI: 3.9-26.6)
In most VAP; reducing Rx to 8 days is not worse than 15 day Rx
But not in non-fermenting Gram negs.
VAP
Rec
urre
nce
(%)
Restricted Therapy in VAP
*Singh et alAJRCCM 2000; 162: 505-11.
Oft quoted;
A trial aimedat proving thevalue of restrictingempirical therapy(not “de-escalation”)
Cipro was used as acompromise placebo
Procalcitonin & De-escalation
Lancet 2010; 375: 463–74
PRORATA trial
630 intensive care patients RCT75% with respiratory tract infection (not VAP)Abx based on routine vs. PCT guided
No mortality difference (21 vs. 20 at 28 d)
K Antibiotic-free days (14 vs. 11.6; p <0.0001)
Summary: Dx/Rx of VAPSuspected VAP
CPIS
Observe Look for other
infection
BAL / ?Mini BAL Gram Stain
Neutrophil <50%<6
>6
Neutrophil >50%
No organism seen
Empirical Rx
Organism seenModified Emp. Rx
Summary: Dx/Rx of VAPEmpirical Rx begun
Positive Cx Negative Cx
De-escalate RxModify Rx
Continue Rx?
Completed 7 days; non-MDRPro-calcitonin K / sub-threshold
Sequential CPIS <6?
ET secretions
YesSTOP!
Current Strategy
N Engl J Med 2006;355:2619-30
740 Patients RCT; invasive dx (BAL)vs. Bronchial aspirateMortality identical (18.9 vs. 18.4%)Targeted Rx same (74.2 vs. 74.6%)No D in Abx-free days, LOS, MODS scores
Resistance Mechanisms
Oxa-beta lactamaseMBL / Carbepenemase
Efflux pumps
Porin loss
Amp-C CephalosporinasePlasmid ESBL
N E J Med 2008; 358: 1271-81
Current Day Concerns
Extended Spectrum Beta Lactamase Klebsiella / E coli
Carbepenem Resistant EnterobacteriaceaeNDM > KPC
MDR Non-fermenters Pseudomonas, AcinetobacterStenotrophomonas, Burkholderia
ESBL in the Developing World
Site Location %ESBLKlebsiella E. coli
AIIMS, New Delhi1 Tertiary Hospital 80% -Mathai 10 Tertiary Hosps. - >60%KGMC, Lucknow2 Neonatal ICU 86% 64%SMF, Chennai Nosocomial: ICU 84% 82%SMF, Chennai Comm. Acquired: ICU 53% 44%
China, Shanghai3 University Hospital 51% 24%Latin America4 SENTRY, Pneumonia 44% 29%
1: Ind J Med Res 2002;115:153-7 2: J Med Microb 2003; 52: 421-5 3: Zhou Yi Xue Za Zhi 2002;82:1476-9 4: Diag Mic Inf Dis 2002; 44: 301-11
KPC? Not our kind of poison!
Lancet ID 2013; 13: 785–96 Klebsiella pneumoniae Carbepenemase
NDM; The ‘Desi’ threat
Lancet ID 2010; 10: 597-602
The “New Delhi” Metalobetalactamase
Treatment of CRE
Colistin and Polymixin B are the onlyantibiotics with consistent in-vitro sensitivity
Resistance to Polymixins ~10% reported from Taiwan
Hetero-resistance has been reported amongst susceptible strains in patients with prior Rx*
No clear RCTs on clinical efficacy*Antimic & Chemo 2008; 52: 351-2
Considering the “concentration” dependent PDAUC / MIC ratio is the best predictor of success
Modelling studies suggest the need for a loading doseNo RCTs on efficacy
Colistin in Rx of CRE
Dosing schedule:
Small case series of 25 patients with 28 episodes of CRAB, VAP*
Rx with Colistimethate alone;Loaded 9 million units (270 mg base) +4.5 million units (135 mg base) q 12 hours82% clinical cure
Colistin in Rx of CRE
*CID 2012; 54: 1720
Optimizing CarbepenemsTime-dependent PDDuration > MIC best predictor of adequacy
1 gm imipenem infused over 1 hour q8vs. 500 mg imipenem infused over 3 hours q8CRAB & Pseudomonas VAPNo clinical outcome differences
54%
75%
Int J Anti Agent 2009; 33: 290-1
Deadly Tigecycline!
CID 2012; 54: 1699–709
Meta-analysis10+3 trials7434 patients
Mortality:Risk dif: 0.7% (p=0.01)
No heterogeneityNo difference with indications
Non-cure Rates
CID 2012; 54: 1699–709
2.7% (0.6-5.2)risk difference for non-cure; implies mortality is due inefficacy of Rx
No heterogeneityNot affected by indication or comparator Rx
Limit Tigecycline: Why?Bacteriostatic drug
Non-linear protein binding; Very large Vd (5-10L/kg); rapid clearance from the blood
Standard dose (100mg load + 50 bd) will yield average levels 0.6 mg/ml; very near MIC breakpoints (<0.5mg/ml - <2.0mg/ml)
Ineffective + may have ?intrinsic toxicityEmergence of resistance during Rx*
Not recommended for primary Rx if alternatives are available.
*CID 2008; 46: 567-70
Combination TherapySystematic review; MDR Acinetobacter infection
12 studies; 1040 patientsOnly 3/12 studies draw a positive conclusion
Carbepenem + Ampi/SulbactamCarbepenem + ColistinMixed: Colistin + RifSulbactam +AGTigecycline + Colistin + RifTigecycline +Rif + Amik
“The available data preclude a firm recommendation with regard to combination treatment or monotherapy.”
42-77% Clinical Success
33-67% Microbial
eradicationEur J Clin Mic & ID 2014; Epub