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Nosocomial Pneumonia

Nosocomial Pneumonia. Hospital Acquired, Ventilator Associated, Healthcare Associated Pneumonia. Outline and Goals. Learn Definitions of types of NP Learn Pathogenesis/Epidemiology Learn Diagnosis Learn Initial Management Learn Impact of NP Learn Prevention of NP.

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Nosocomial Pneumonia

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  1. Nosocomial Pneumonia Hospital Acquired, Ventilator Associated, Healthcare Associated Pneumonia

  2. Outline and Goals • Learn Definitions of types of NP • Learn Pathogenesis/Epidemiology • Learn Diagnosis • Learn Initial Management • Learn Impact of NP • Learn Prevention of NP

  3. Hospital Acquired Pneumonia • “occurs 48 hours or more after admission” • “was not incubating at the time of admission” • Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia • American Thoracic Society and the Infectious Diseases Society of America • Am J Respir Crit Care Med Vol 171. pp 388–416, 2005

  4. Ventilator Associated Pneumonia • > 48 to 72 hours on closed ventilator • Non-Invasive Ventilation not a factor

  5. Healthcare-Associated Pneumonia • Nursing Home/LTCH resident • >48Hr hospital stay in past 90 days • Within past 30 days had: • Wound Care or I.V. Therapy • HD or Hospital Clinic visit

  6. Pathogenesis • Colonization of Lower Respiratory Tract (LRT) • Vulnerable Host Defenses

  7. Colonization LRT • Microaspiration • Introduction by devices (catheters, aerosolized material) • Direct Leakage around ETT cuff • Biofilm

  8. Vulnerable Host Defenses • Cellular/Humoral Defenses • Immunosupressed, infected, surgery, organ failure, recent antibiotics, frequent transfusions of blood/blood products • Mechanical Defenses • Turbinates, vocal chords, ciliated epithelium, cough, acidified stomach

  9. VAP Incidence • 90% of the HAP in the ICU is VAP • Incidence increases over time but risk highest early in vent course • 3%/day from day 0 to 5, 2%/day from day 5-10, 1%/day after • So risk starts at minute zero of intubation

  10. Microbiology • Frequently polymicrobial • Multidrug Resistance (MDR) Problem • Similar spectrum in all types NP • Viral/Fungus very uncommon

  11. Aerobic Gram Negatives • Pseudomonas • Klebsiella • Acinetobacter • Very Institution Specific • Stenotrophomonas • Legionella

  12. Gram Positives • Most commonly staph • ICU in USA MRSA>MSSA • Pneumococcus much less common

  13. Risk for MDR • HCAP risks • >5 days since admission • Antibiotics in past 90 days • Immunosupressed • High MDR rate in hosp/unit

  14. Suspect Pneumonia if: • New/Progressive CXR findings • Clinical Infection Findings • Fever, Leukocytosis, Leukopenia • Respiratory Findings • Purulent Sputum, Deoxygenation

  15. Additional Clinical Clues • Mental Status Change in Elderly • New Crackles, Egophony • Worsening Dyspnea or Cough • Increased Need for Vent Support • Increased Suction Requirements

  16. Diagnosis: Cultures • Sensitivity and specificity poor with clinical criteria alone • especially with vented patients • CXR+ and 2/3 clinical findings present • sensitivity 69% • specificity 75% • Fabregas et al, Thorax1999;54:867–873

  17. Lower Respiratory Cx • Bronchoscopy or ETT Aspiration • Both good NPV (>90%) • ETT aspirate can’t distinguish colonizers; may lead unnecessary abx • Bronch invasive; not as accessible

  18. Blood Cultures • Always obtain • Limited sensitivity (25%)* • May be extrapulmonary so limited specificity* • For non-vented patients may be only accessible culture • *Luna CM et al, Chest1999;116:1075

  19. Microbiological Diagnosis • Culture if clinically suspect NP, BEFORE antibiotics if possible • Always try LRT Cx or Sputum • Always blood culture • Avoid unnecessary sampling to prevent unneeded abx and MDR

  20. Initial Management • Empiric early therapy with APPROPRIATE antibiotics • Do not delay therapy for microbiological sampling • Delay in therapy has higher mortality

  21. Appropriate Antibiotics? • HAP with no MDR risks? • Becoming less common, but can use • Ceftriaxone • Ampicillin/sulbactam • Moxifloxacin

  22. Appropriate Antibiotics • Otherwise should start with • Antipseudomonal therapy • Cefepime, Imipenem, Meropenem • plus • MRSA Therapy • Vancomycin, Linezolid

  23. Impact of HAP/VAP • 25% ICU infections HAP • Most common cause for antibiotic use in ICU - likely contributor to MDR • HAP extends LOS by 7-10 days • Mortality ranges 30 - 70% • Cost of one case $40,000

  24. Prevention • We give patients this. • The chief complaint on entering the health care system is never: • “I have ventilator associated pneumonia” • Everyone who touches the patient has a responsibility to prevent it.

  25. Hand Washing • Before and after every patient contact however small • Dirty hands are lethal weapons • Soap/Water 30 seconds • (“Happy Birthday” or “ABC” twice) • Alcohol Scrub acceptable

  26. Circuit Integrity • The ventilator tubing (called “circuitry”) is changed weekly • More frequent changes do not reduce VAP • Avoid opening it unnecessarily - use in-line suction catheter if possible

  27. Patient Positioning • Elevate Head of Bed (HOB) to 30-45˚ • Reduces clinical rate from 34% to 8%* • Reduces culture rate from 23% to 5% * • Every vented patient should have HOB >30˚at all times from the start unless absolute contraindication • Lancet 1999 Nov 27;354:1851

  28. Judicious Intubation • Cannot get VAP if not on the Vent • NIPPV good for CHF, COPD • Not good for AMS, Secretions • Do not delay necessary intubations

  29. Removal of Ventilator • Cannot get VAP if not on the Vent • Patients need aggressive weaning • Includes daily waking from sedation • Includes daily wean trials if meets criteria (see weaning protocol)

  30. IHI Bundle • HOB Elevation • Daily Sedation Vacation • Daily Wean Trials • DVT Prophylaxis • GI Ulcer Prophylaxis

  31. Some institutions self-report VAP rates of 0% after adopting IHI bundle • Only 3/5 recommendations directly impact VAP

  32. Summary • HAP/VAP/HCAP significant cause of hospital/ICU Morbidity • Significant cost in resources, patient safety and likely mortality • Significant public health problem; possibly fueling development of MDR

  33. Summary • Once suspect diagnosis must attempt to confirm with cultures • Empiric antibiotics must be started quickly • Coverage for MRSA and Pseudomonas in most cases is warranted

  34. Summary • Rapid de-escalation of antibiotics • Narrow if pathogen known • Remove if improves and cultures negative

  35. Summary • Prevention Essential • Handwashing and Infection Control • HOB elevation • Avoid unnecessary intubation • Wake and Wean Aggressively • Maintain Circuitry Integrity

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