1 / 80

THE DIAGNOSTIC AND THERAPEUTIC DEVELOPMENT OF HOSPİTAL ACQUIRED PNEUMONIA

THE DIAGNOSTIC AND THERAPEUTIC DEVELOPMENT OF HOSPİTAL ACQUIRED PNEUMONIA. Turhan Ece, MD Professor of Pulmonary Medicine İstanbul University, İstanbul Medical School, Department of Pulmonary Medicine. HEALTCARE ASSOCIATED PNEUMONIA. H ospital A cquired P neumonia ( HAP )

ingo
Download Presentation

THE DIAGNOSTIC AND THERAPEUTIC DEVELOPMENT OF HOSPİTAL ACQUIRED PNEUMONIA

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. THE DIAGNOSTIC AND THERAPEUTIC DEVELOPMENT OF HOSPİTAL ACQUIRED PNEUMONIA Turhan Ece, MD Professor of Pulmonary Medicine İstanbul University, İstanbul Medical School, Department of Pulmonary Medicine

  2. HEALTCARE ASSOCIATED PNEUMONIA • Hospital Acquired Pneumonia (HAP) • Ventilator Associated Pneumonia (VAP) • HealtCare Associated Pneumonia (HCAP)

  3. HEALTCARE ASSOCIATED PNEUMONIA • HAP; occurs ≥ 48 hours after admission • VAP; occurs ≥ 48 hours after intubation • HCAP; occurs ≥ 48 hours hospitalized within 90 days, resided in a nursing home, received recent IV antibiotic, chemotherapy, or wound care within the past 30 days, attended a hemodialysis clinic

  4. HEALTCARE ASSOCIATED PNEUMONIA • HAP, VAP, HCAP • Multidsiplinary • Epidemiology and Pathogenesis • Modifiable risk factors • The variability of bacteriology • Early onset pneumonia without MDR* pathogen risk Late onset pneumonia with MDR* pathogen risk *P.aeruginosa, Acinetobacter spp, MRSA

  5. HAP- Epidemiology • The socond most common nosocomial infection • HAP increases hospital stay 7-9 days and cost 40.000 USD • HAP occurs 5-10 cases per 1000 hospital admission ( 6-20 fold in MV patients) • HAP accounts 25 % of all ICU infections Am Respir Crit Care Med 2005;171: 388-416

  6. The Epidemiology of HCAP • An increase in mortolity for HAP and VAP is associated with MDR pathogens • Bacteria cause most cases of HAP and VAP is polymicrobial espacially high in patients with ARDS • HAP, VAP, and HCAP are commonly caused by AGNB ( P.aeruginosa,K.pneumoniae, Acinetobacter sp. Enterobacter sp.)55- 85% by GPC ( S.aureus, MRSA) 20- 30% • Rates of L.pneumophila is high when water supply colonisation and ongoing construction • Nosocomial virus and fungal infections are uncommon Am Respir Crit Care Med 2005;171: 388-416

  7. VAP- Epidemiology • VAP occurs in 9-27 % of all ıntubated patients • During the first 5 days 3% During 5 to 10 days 2% After 10 days 1% • Half of VAP occur within 4 days of MV

  8. The Pathogenesis of HAP • Sources of pathogenesis for HAP include healthcare devices, the environment and the transfer of microorganism • Host and treatment related colonization factors; severity of underlying disease, prior surgery, exposure to antibiotics and invasive respiratory devices

  9. The Pathogenesis of HAP • Aspiration of oropharyngeal pathogens, or leakage of secretions • Inhalation or direct inoculation of pathogens, hematogenous spread from infected IV catheters bacterial translocation from GI tract • Infected biofilm in the tracheal tube • The stomach and sinuses may be potential reservoirs

  10. Clasification of HAP and VAP • Early- onset HAP and VAP Occurring within the first 4 days Caused by antibiotic sensitive bacteria Prior antibiotics or hospitalization within 90 days are at greater risk for MDR • Late- onset HAP and VAP Occurring after 4 days Caused by MDR pathogens

  11. HCAP- Risk factors for MDR pathogens • Antimicrobial therapy in preceiding 90 d • Current hospitalization of 5 d or more • High frequency of antibiotic resistance in the community or hospital unit • Presence of risk factors for HCAP: Hospitalization for ≥ 2 d within 90 d Residence nursing home or extended care facility Home infusion therapy, wound care Chronic dialysis within 30 d Family member with MDR pathogen • Immunosupressive disease and/ or therapy AJRCCM 2005; 171: 388- 416

  12. The Pathogen of HAP and VAP in Turkey (%) Toraks Dergisi 2002;3 Ek 4: 1-13

  13. Mojor Points and Recommendations for Diagnosis • Medical history and physical examination • CXR ( multilobar? Effusion? Cavitation?) • Purulent tracheobronchitis vs tracheal colonization • Arterial blood gas, CBC and biochemistry • All patients with suspected VAP should have blood cultures collected. • Diagnostic thorocentesis • Samples of LRT secretions should be obtained • A sterile culture of LRT secretions rules out bacterial pneumonia • For patients with ARDS should be done more diagnostic testing

  14. The Diagnosis of VAP PITA* PSB,BAL,PTC** • Sensitivity (%) 77 75 • Specificity (%) 84 88 • PPV 4.80 6.25 • NPV 0.27 0.28 Conclusion: PITA may be a reliable alternative to PSB,BAL,PTC * Postintubation tracheal aspiration (PITA) ** Plugged telescoping catheter (PTC) Chest 2006;130: 956- 961

  15. Clinical strategy • New or progressive radiologic infiltrate + fever > 38 C, leukocytosis or leukopenia and prulent secretions • The results of emiquantitative LRTS cultures and serial clinical evaluations, by Day 3 • High probability of pneumonia or sepsis , prompt therapy is required • Delays in the initiation of appropriate antibiotic therapy can increase the mortality of VAP • The clinical pulmonary infection score (CPIS)< 6 : low risk for early discontinuation of empiric treatment

  16. Empiric Antibiotic Therapy for HAP HAP, VAP or HCAP Suspected Late Onset (≥ 5 days) or Risk Factors for MDR Pathogens No Yes Limited Spectrum Antibiotic Therapy Broad Spectrum Antibiotic Therapy For MDR Pathogens

  17. HKP- Hasta grupları ve etkenler Toraks Dergisi 2002;3 Ek 4: 1-13

  18. Empiric Antibiotic Therapy for Early Onset HAP Potential Pathogen RecommendedAntibiotic • S. Pneumoniae Ceftriaxone • H. Influenzae or • S. aureus ( MSSA) R. Fleuroquinolons • Antibiotic sensitive EGNB or E.coli Ampicillin/ sulbactam K. Pneumoniae or Enterobacter spp. Ertapenem Proteus spp. S. marcescens Toraks Dergisi 2002;3 Ek 4: 1-13

  19. Erken 4. gün Temel etkenler S. pneumoniae H. influenzae M.catarrhalis S. aureus ( MSSA) Monoterapi Betalaktam+betalakmaz inhibitörü * veya 2.-3. kuşak nonpseudomonal sefalosporin veya Yeni kinolon** Empiric Antibiotic Therapy for HAP Toraks Dergisi 2002;3 Ek 4: 1-13

  20. Empiric Antib iotic Therapy for Late Onset HAP Potential Pathogen RecommendedAntibiotic • Pathogens of Antipseudomonal SS Early Onset HAP (Cefepime, Ceftazidime) • MDR pathogens; or P.aeruginosa Antipseudomonal carbapen K.pneumoniae (ESBL) (imipenem or meropenem) Acinetobacter spp. or β- lactam/ β- lactamase inhibitor (piperacillin- tazobactam) plus Antipseudomonal FQ or AG plus • MRSA Vancomycin or Linezolid • Legionella pneumophila

  21. Geç 5 gün Enterobacter spp. K. pneumoniae S. marcescens E. coli Diğer Gram negatif çomaklar S. aureus Temel etkenler Monoterapi** Betalaktam+betalakmaz inhibitörü* veya 3.kuşak nonpsödomonal sefalosporin veya Kinolon (Ofloksasin /Siprofloks) HKP- Grup 2

  22. Yüksek riskli, çoklu dirençli bakteri inf. Son 15 günde AB kullanımı MV> 6 gün YBÜ> 48 saat Acil entübasyon Mortalite artıran faktör Bilateral, multilober, kaviter tutulum, apse, ampiyem, hızlı radyolojik progresyon, PaO2/FiO2< 250 Ağır sepsis/ septik şok Kombine tedavi Antipseud. Penisilin veya Antipseud. sefalosporin veya Karbapenem + Aminoglikozid veyaKinolon (Ofloks/Siprofl) HKP- Grup 3

  23. The prognosis of HCAP • The crude mortality rate for HAP 30- 70 % • The mortality related to the HAP 33- 50 % • Increased mortality rates; bacteremia ( P.aeruginosa, Acinetobacter spp) medical illness ineffective antibitic therapy

  24. Mojor Points and Recommendations for Initial Antibiotic Therapy • Select an empiric therapy based on risk factors and local mycrobiliogic data • Initial antibiotic therapy should be given promptly • Inapropriate therapy is a major risk factor for excess mortality • Select a different antibiotic class for patients who have recently received an antibiotic

  25. Mojor Points and Recommendations for Optimal Antibiotic Therapy • Initial therapy should be administered to all patient intravenously • Aerosolized antibiotics may be considered as adjunctive therapy • Combination therapy should be used • The aminoglycoside can be stopped after 5-7 days • Monotherapy can be used after the results of LRTS culture • If patients receive an appropriate therapy, efforts should be made to shorten ( 7-8 days)

  26. VIP’ li erişkinlerde 8- 15 günlük antibiyotik tedavisinin karşılaştırılması • Amaç - VİP’li hastalarda 8 günlük tedavinin 15 günlük tedavi kadar etkili olabileceğini belirlemek • Kurgu - Prospektif, randomize, çift kör, 401 VİP’li hasta • Bulgular - Tedavi: 15 gün- 8 gün mortolite artışı yok: %18.8- %17.7 rekürren infeksiyon:%28.9- %26.0 Antibiyotiksiz gün: 13.1- 8.7 p< 0.01 • Sonuç - 8 günlük tedavi 15 günlük tedavi ile karşılaştırılabilir etkinliktedir. Kısa süreli tedavi antimicrobial direnç oluşumunu azaltabilir. JAMA 2003;290:2588-2598

  27. Mojor Points and Recommendations for selected MDR pathogens • If P.aeruginosa pneumonia is documented, combination therapy is recommended • If Acinetobacter speices are documented, the most active agents are the carbapenems, sulbactam, colistin and polymyxin • If ESBL Enterobacteriaceae are isolated, then monotherapy should be avoided ( 3.JSS) • Adjunctive therapy with an inhaled AG or polymyxin for MDR GN pneumonia should be considered • Linezolid is an alternative to vancomycin for the treatment of MRSA VAP • Antibiotic restriction and cycling may reduce the frequancy of antibitic resistance

  28. VİP- Levofloxacin vs Imipenem/cilistatin Levo + Imip+ p Klinik başarı(%) 58.6 63.1 NS Mortalite (%) 11 13.1 NS VİP empirik tedavisinde; Levofloxacin,Imipenem/cilistatin kadar etkili Levo.( 750 mg/ gün) + Vancomycin  APAB Imip.(3-4 x 500-1000mg/ gün) + Vancomycin  APAB Chest 2003; 124(4): 79s- 80s

  29. Gram pozitif : 1019 S. Aureus: 339 MRSA : 160 Linezolid 600 mg 2x1 ve Aztreonam 1-2 gr 3x1 vs Vancomycin 1 gr 2x1 ve Aztreonam 1-2 gr 3x1 Lin. Van. Sağ kalım %:80 63.5 p= 0.03 Klinik kür %: 59 35.5 p< 0.01 Chest 2003; 124: 1789- 1797 MRSA-HKP: Linezolid vs Vancomycin

  30. VİP- P. aeruginosa/Piperacilin • Dirençli suşlar: % 25 • Betalactam/AG/ Ciprofloxacin direncide  • Önceden FQ kullanımı direnç olasılığını  • Dirençli suşlarda mortalite: % 59 Clin Infect Dis 2002; 34: 1047

  31. VİP- Lokal AB • Travmalı hastalarda: Enterik Gram neg. bak.VİP’de TOBi yararlı YBÜ(gün) MV(gün) Sürvi(%) İki IV AB 16 15.4 80 IV AB+ TOBI 11 9.9 91 • Yüksek dirençli Gram netatif bak. VİP’ de Colistin yararlı Colistin 50 mg + SF 50 ml trakeal tüp yoluyla 8/ 11 olgu iyileşmiş Chest 2003; 124(4): 79s- 80s

  32. VİP- AB değişikliği Grup 0 1 2 3 Olgu (n=56) 19 8 19 10 Yetersiz AB (%) 12.7 8.1 6.9 5.9 Kültür- değ. (%) 37.5 15.8 14 Kanıtsız- değ. (%) 1.25 23.7 37.2 Mortalite (%)21.1 25 57.9 80 YBÜ ve MV süresi uzaması ile değişiklik  Kanıtsız AB değişimi mortalite artışı ile korele Yetersiz AB bir kez değiş. mortalite artmıyor Chest 2003; 124(4): 79s

  33. Assessment of Nonresponders Wrong Diagnosis Atelectasis,PE, ARDS Pulmoner hemorrhage Underlying disease Neoplasm Wrong Organism Drug resistance Pathogen: (bacteria,mycobacteria, virus,fungus) Inadequate AB Therapy Complication Empyema or Lung abscess C.difficile Colitis Occult Infection Drug fever

  34. HAP, VAP or HCAP Suspected Obtain LRTS for Microscopy &Culture Begin Empiric Antimicrobial Therapy Based on Algorithms and Local Microbiologic Data Days 2 & 3: Check Cultures & Assess Clinical Response Clinical Improvement No Yes Cultures – Search for other pathogens, Complications Cultures + Adjust Antibiotic Therapy Cultures – Consider Stopping Antibiotics Cultures + De-escelate Antibiotics

  35. HAP- Take Home Messages • Avoid untreated or inadequate treated HCAP • Recognize the variability of bacteriology from one hospital to another • Avoid the overuse of antibiotics by focusing on accurate diagnosis • Apply prevention strategies aimed at modifiable risk factors

  36. Trakeal aspirasyon kateterleri • Açık tek kullanımlık • Kapalı çok kullanımlık* daha ekonomik çapraz kontaminasyon için daha güvenli • Biofilm koruma teknolojisi** *CDC. Infect Control Hosp Epidemiol 1998;19: 304 ** Jansen B. Journal of Industrial Microbiology 1995;15: 391- 6

  37. I- Genel: surveyans, eğitim, el yıkama- bariyer, dezenf- steril,izolas, AB kontrolü, aşılama II-Hastalara yönelik: kısa yatış,oral hijyen, AB profl- tedavi, ortak araç kullanmama,hasta eğitimi, post op analjezi, gereksiz s.ülser profilaks. kaçınma III-YB hastalarına yönelik: NPPV önceliği, beslenme desteği, enteral beslenme, aspir.önlenme, oral entüb, kuf basıncı, erken ekstüb, subglottik asp, kapalı asp. kateteri, ventilator devreleri bakımı IV- Özel: SGID, Ig, IFG NP korunma önlemleri

  38. Subglottik aspirasyon- Tüp Kafı • Tüp kafı üstünde kolonize sekresyon; kaf basıncı azalması tüp değiştirme- çıkarma • Tüp kafı basıncı yeterli olmalı • Tüp kafı üst kısmının drenajı VİP insidensi azalmakta Valles J. Ann Intern Med 1995; 122: 179- 86 Rello J. Am J Respir Crit Care Med 1996; 154: 111- 5

  39. Ventilatör devrelerinin değişimi-VAP Değişim 2 gün 7 gün p VAP n= 38 8 VAP /gün 16.7/ 1000 8.2/ 1000 < 0.001 7 günde değişim daha güvenli Han JN. Respir Care 2001; 46(9): 891- 6

  40. Surveyans • En yüksek infeksiyon oranı ve antibiyotik direnci olan bölümler • İnfeksiyon endemi oranını belirlemek • Sonuçlar ilgili bölümlere ulaştırılmalı Hastane inf. %32 azalmakta Haley RW.Am J Epidemiol 1985;121: 183-205

More Related