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Pneumonia

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Pneumonia

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  1. Pneumonia

  2. Definitions • New Pulmonary infiltrate that resembles bacterial pneumonia on CXR • Hospital acquired Pneumonia - > 48 hrs after admission • Ventilator Associated Pneumonia - > 48 hrs after Intubation • Health-care Associated Pneumonia – - previous hospitalization within 30 days - IV antibiotics, HD, within 30 days - transferred from another health care facility. - Will have to be stratified

  3. USA dataKollef et al Chest 2005;128:3854-3862

  4. Pathogenesis • Colonization of oropharynx • Aspiration of oropharyngeal secretions into lower respiratory tract • Compromise of the normal host defense mechanisms (ETT)

  5. CRB-65 • C – confusion • R – respiration rate >30/min • B – blood pressure MAP < 60 • 65 – age > 65

  6. Diagnosis • Clinical Features – fever, leucocytosis, purulent sputum, • CXR – pneumonia only 1/3rd of all ICU CXR infiltrates • 40% pulmonary infiltrates missed in CXR • 25% infiltrates persist after 4 weeks • Tracheobronchitis – fever & purulent sputum (CDC) • 50% of ARDS will develop Pneumonia

  7. Diagnosis – Tracheal Aspirates • Neg culture excludes pneumonia but +ve culture cannot be used to confirm it • Microscopic analysis – presence of macrophage & >25 neutrophils/hpf, epithelial cells <25/hpf • Quantitative culture – collect 1 ml in sterile trap without saline. • TA 105(75%), BAL 104(82%), PSB 103(90%) • BAL – 3% intracellular organisms

  8. A Randomized Trial of Diagnostic Techniques for Ventilator-Associated PneumoniaThe Canadian Critical Care Trials Group • In conclusion, we found that endotracheal aspiration with nonquantitative culture of the aspirate to diagnose ventilator-associated pneumonia is associated with clinical outcomes and antibiotic use similar to those that are associated with bronchoalveolar lavage and quantitative culture of the bronchoalveolar-lavage fluid NEJM December 21, 2006,355:2619-2630

  9. Microbiology of VAP • Early onset VAP • MSSA • Strep pneumoniae • H.Influenzae • Non resistant GNEB

  10. Microbiology of VAP • Late Onset VAP • Resistant GNEB • MRSA • Pseudomonas • Acinetobacter

  11. Choice of Antibiotics • Antimicrobial spectrum • Local Microbiology • Effective dose • Pharmacokinetics • Adverse effects • Cost • Availability

  12. HAP treatment recommendations was published in 2008 for Asian Countries by Asian HAP Working Group

  13. Initial Approach to Empirical Therapy HAP or VAP Suspected Evaluation • Risk Factors for MDR pathogen • Time of onset (early or late ) • Local microbiologic data and resistance pattern • Patient status • LRT sample Gram Stain • Allergy to medication • Underlying co-morbidities • Formulary restrictions • Cost Select Empirical Antibiotic therapy Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92

  14. Initial Empiric Antibiotic treatment for early onset HAP (Table I) *Antibiotic options should depend on local epedimiology of etiologic pathogens. $ The frequency of macrolide-resistant S. pneum and MDR S pneum is increasing; levofloxacin or moxifloxacin ae preferred to ciprofloxacin and the role of other new quinolones has not been established. Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92

  15. Initial Empiric Antibiotic treatment for late onset HAP (Table II) *if an ESBL strain such as K. pneum or an Acinetobacter sp. Is suspected the a carpenem is a reliable choice. If L. pneumophilia is suspected then the combination antibiotic regimen should include a macrolide (eg. Azithromycin) or a fluoroquinolone (eg. Ciprofloxacin or levofloxacin) should be used rather than an aminoglycoside. $ If MRSA risk factors are presenr or there is a high incidence locally. Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92

  16. Initial Empiric Antibiotic treatment for early onset VAP (Table III) Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92

  17. Initial Empiric Antibiotic treatment for late onset HAP (Table IV) Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92

  18. Treatment Recommendations for MDR pathogens

  19. MRSA • First line treatment : Teicoplanin or Vancomycin. • Teicoplanin as compared to Vancomycin has fewer side effects and does not require serum monitoring levels. • Linezolid to be reserved as second tier agent. Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92

  20. P. Aeruginosa • First line : Piperacillin/ tazobactum or carbapenems +/- aminoglycosides or fluoroqinolone • Fluoroqinolones offer theoretical advantage of improved bioavailability in respiratory tract. • Ciprofloxacin or LevofloxacinFluoroqinolones preferred in combination therapy • In unresponsive patients Polymyxin B or Colistin in combination with fluoroqinolone Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92

  21. Acinetobacter sp. • First Line: Cefoperazone/ sulbactam and/or tigecycline • Sulbactam an enzyme inhibitor has direct activity against Acinetobacter. • In unresponsive patients : Polymyxin B or Colistin Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92

  22. Antibiotic regimens against specific antibiotic – resistant pathogens Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92

  23. Duration of Treatment • Asian HAP Working Group recommends the initial empirical antibiotic treatment should continue for 7 to 14 days. • If MDR pathogen is identified then the treatment may be continued for up to 14 days. • Patient response should be evaluated frequently with consideration given to de-escalating therapy when appropriate. Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92

  24. Microorganism Profile – Ventilator Associated Pneumonia (VAP)Updated on a quarterly basisKalinga Hospital , Mixed ICU

  25. Device Associated Infection Rates.Ventilator Associated Pneumonia per 1000 Device Days.Kalinga Hospital , Mixed ICU

  26. Extra Length of Stay Updated on a quarterly basisKalinga Hospital , Mixed ICU References:HAI: Health Care Associated Infection; CLABSI: Central Line Associated Blood Stream Infection; VAP: Ventilator Asscciated Pneumonia; CAUTI: Catheter Associated Urinary Tract Infection.

  27. Percentage of Deaths by HAI Updated on a Quarterly Basis Kalinga Hospital , Mixed ICU References:HAI: Health Care Associated Infection; CLABSI: Central Line Associated Blood Stream Infection; VAP: Ventilator Asscciated Pneumonia; CAUTI: Catheter Associated Urinary Tract Infection.

  28. CAP-128HCAP-7VAP-35(5 outside)

  29. Nosocomial Pneumonia KHL - 2006 • VAP (ICU acquired) - 9 – Pseudomonas - 5 - Klebsiella - 1 - MSSA - 1 • VAP (other hospital) – 1 • HAP (Aspiration Pneumonia) – 8 - Klebsiella – 5

  30. KHL-Tracheal Aspirates ICU Jun-Sep 07 • Acinetobacter – 12 • Pseudomonas – 9 • Klebsiella – 6 • E. coli – 2 • Enterobacter – 2 • Proteas – 1 • Providencia – 1 • MRSA – 6 • MSSA – 2 • Non H Streptococcus - 1

  31. KHL – Tracheal AspiratesSensitivity Jun-Sep 07 • Ceftazidime – 23% • Amikacin – 23% • Cefoperazone+sulbactum – 56% • Levofloxacin – 19% • Piperacillin+tazobactum – 37% • Meropenem – 53% • Imipenem – 76%

  32. Resolution • CRP – follow up after 72 hours. If fall in CRP is > 50% then your antibiotic is working

  33. Prevention of VAP • Handwashing • Raising the head of the bed to at least 30 degrees above horizontal • Guidelines for oral care, • Aspiration of subglottic secretions,

  34. Ventilator Bundles • Elevation of head end of bed • Daily sedation vacations & assessment for extubation • Peptic ulcer disease prophylaxis • DVT prophylaxis

  35. Saline installation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia Caruso P, Demarzo SE, Ruiz SAL, Denari S, Deheinzelin D. .ATS 2006 International Conference; May 19-24, 2006; • The incidence of VAP was significantly less in the arm receiving saline. Only 10.7% of these patients suffered VAP compared with 23.5% of those in the control group • Routine use of saline prior to suctioning, as is the standard practice in US ICUs, helps to prevent VAP without exposing the patient to any evident risk.