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TURKISH THORACIC SOCIETY

TURKISH THORACIC SOCIETY. HOSPITAL ACQUIRED PNOMONIAE CONSENSUS STATEMENT,2008. Oğuz KILINÇ (Chair) Turhan ECE (Secretary) Dilek ARMAN Nahit ÇAKAR Nedim ÇAKIR Ali GÜNERLİ Eyüp Sabri UÇAN

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TURKISH THORACIC SOCIETY

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  1. TURKISH THORACIC SOCIETY HOSPITAL ACQUIRED PNOMONIAE CONSENSUS STATEMENT,2008

  2. Oğuz KILINÇ(Chair) Turhan ECE (Secretary) Dilek ARMAN Nahit ÇAKAR Nedim ÇAKIR Ali GÜNERLİ Eyüp Sabri UÇAN Sercan ULUSOY Haluk VAHAPOĞLU COMMITTEE MEMBERS Halis AKALIN Füsun ALATAŞ Feza BACAKOĞLU Kadir BİBEROĞLU Semra ÇALANGU Haluk C. ÇALIŞIR Hülya ELLİDOKUZ Zeynep GÜLAY Selma KARABEY Volkan KORTEN Emine OSMA Metin ÖZKAN Halit ÖZSÜT Tülay YARKIN AUTHORS

  3. NEW DEFINITION • Healthcare-associated pneumoniae (HCAP) • Nosocomial tracheobronchitis • Ventilator-associated tracheobronchitis

  4. NEW DEFINITION • Healthcare- associated pneumoniae; • Hospitalization for 2 d or more in the preceding 90 d • Residence in a nursing home or extended care facility • Home infusion therapy (including antibiotics) • Chronic dialysis within 30 d • Home wound care • Family member with multidrug-resistant pathogen

  5. NEW DEFINITION • Nosocomial tracheobronchitis* • When fever, leukocytosis, purulent sputum, and a positive culture of a sputum or tracheal aspirate are present without a new lung infiltrate, *Occurs 48 hours or more after admission, which was not incubating at the time of admission

  6. NEW DEFINITION • Ventilator- associated tracheobronchitis * • When fever, leukocytosis, purulent sputum, and a positive culture of a sputum or tracheal aspirate are present without a new lung infiltrate *Occurs 48 hours or more after mechanically ventilation, which was not incubating at the time of MV

  7. PATHOGENESIS • Aspiration of oropharyngeal pathogens, • Inhalation • Hematogenous spread

  8. ETIOLOGY • Early- onset (3.-4. day) • Streptococcus pneumoniae, • Haemophilus influenzae • Methicilline sensitive Staphylococcus aureus’tur • Late- onset (after 5 day) • P. aeruginosa • Acinetobacter spp. • Enterobacter spp. • Klebsiella spp. • MRSA

  9. RISK FACTORS (increased mortality) • Inappropriate treatment • Previous antibiotic usage • Duration of hospital stay and ICU • Prolonged MV • Multilober and/or bilateral pulmoner infiltration • Severity of underlying diseases APACHE II, SAPS • Severe sepsis/septic shock, multiorgan disfunction syndrom (MODS) • Elderly age (>65) • PaO2/FiO2< 240

  10. RISK FACTORS (increased mortality) • MDR pathogens • P. aeruginosa • Acinetobacter spp* • Stenotrophomonas maltophilia • S. aureus(methicilline resistant) MRSA

  11. DIAGNOSIS- Clinical • New or progressive infiltrate on chest x-ray and • > 38 0C fever • Leukocytosis or Leukopenia • Purulen sputum • Decline in oxygenation

  12. DIAGNOSIS-CPIS Clinical Pulmonary Infection Score (CPIS) CPIS > 6 is often regarded as consistent with a diagnosis of pneumonia especially in VAP

  13. DIAGNOSIS- first step tests • Sputum,pleural fluid, tracheal secretion culture • Two step, blood culture

  14. DIAGNOSIS- second step tests • BAL • PSB • TTA • FNAB • Open lung biopsy

  15. CLASSIFICATION AND TREATMENT • GROUP 1 • Early- onset • GROUP 2 • Late- onset (risk factors for mortality and MDR pathogen (-) • GROUP 3 • Early-onset /Late onset (risk factors for mortality and for MDR pathogen (+)

  16. CLASSIFICATION AND TREATMENT Pathogens

  17. Group 1 (Monotherapy) Ampisilin-Sulbaktam/ Co-amoksilav or Cefuroxime/Ceftriaxone or Levofloxacin/ Moksifloxacin *

  18. Group 2 (Monotherapy) Sulbaktam- ampicilline or Ceftriaxone/Cefotaxime orOfloxacine or Levofloxacin/Moksifloxacin or Piperacillin-tazobaktam

  19. Group 3 (Monotherapy/ Combination) Piperacillin- tazobaktam or Ceftazidim, Cefepime, Cefoperazon-Sulbaktam or Imipenem, Meropenem  Amicasin or Ciprofloxacin or Colistin** Linezolid***, Teikoplanin, Vankomycine *Combination therapy for MDR pathogens. After 72 hrs If CPIS ≤6 swicth monotherapy ** Especially in MDR pathogens ***Don’t use Linezolid empirically

  20. DURATION OF TREATMENT • If patients receive an initially appropriate antibiotic regimen, efforts should be made to shorten the duration of therapy from the traditional 14 to 21 days to periods as short as 7 days, provided that the etiologic pathogen is not P. aeruginosa, and that the patient has a good clinical response (CPIS ≤6) with resolution of clinical features of infection

  21. RESPONSE TO THERAPY • Resolution of fever • Clinical improvement • WBC count • PaO2/ FiO2 improvement • CPIS ≤ 6 • CRP value decrease %40 at 4. day

  22. Prevention • Hospital Infection Association • Turkish Thoracic Society “Guidelines for Prevention of Hospital Acquired pneumonia”

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