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Pneumonias HAP/HCAP/VAP

Pneumonias HAP/HCAP/VAP. Salim A Baharoon MD Infectious Disease / Critical Care King Saud Bin Abdulaziz University Riyadh. Definitions. HAP : Pneumonia that occurs 48 hours or more after admission and did not appear to be incubating at the time of admition . Early and Late onset

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Pneumonias HAP/HCAP/VAP

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  1. Pneumonias HAP/HCAP/VAP Salim A Baharoon MD Infectious Disease / Critical Care King Saud Bin Abdulaziz University Riyadh

  2. Definitions • HAP: Pneumonia that occurs 48 hours or more after admission and did not appear to be incubating at the time of admition. • Early and Late onset • VAP: A type of HAP acquired at 48-72 hours after intubation. • Early and Late onset • HCAP: Non hospital patient with healthcare contact • IV therapy, wound care, chemotherapy within 30 days • Nursing home or long term care facility (Nursing Home Pneumonia) • Hospitalization >2 days ore more in past 90 days • Attendance at hospital or HD within 30 days • Family member with a MDR pathogen ATS/IDSA Am J Respir Crit Care Med. 2005;171: 388-416

  3. Diagnosis • Progressive infiltrate on lung imaging and clinical characteristics such as: • Fever • Purulent sputum • Leukocytosis • Decline in oxygenation • Radiographic findings plus two of the clinical findings. • 69% sensitivity and 75% specificity for pneumonia (autopsy as reference)

  4. Blood cultures, limited role, sensitivity is only 8% to 20% Sputum neither sensitive, nor specific Tracheo-bronchial aspirates- high sensitivity does not differentiate between pathogen and colonizer Quantitative cultures increase specificity of the diagnosis of HAP. BAL, PSB’s do not differ from less invasive tests in terms of sensitivity, specificity or, more importantly, morbidity and mortality. Negative lower respiratory tract cultures can be used to stop antibiotic therapy in a patient who has had cultures obtained in the absence of an antibiotic change in the past 72 hours. Role of rapid diagnostic test (PCR) (Multiplex PCR) Imperfect diagnostic tests

  5. Epidemiology Study of 4543 pts. with Culture Positive Pneumonia: Incidence (%) • HAP is the second most common nosocomial infection in the US • HAP increased hospital stay by an average of 7-9 days per patient • Estimated occurrence of 5-10 cases per 1,000 hospital admissions • 0.88 per 1000 patients admission in Taif (1999-2003) • 0.5 per 1000 patient days of admission in Iran • HAP accounts for up to 25% of all ICU infections and more than 50% of antibiotics prescribed Kolle MH, et al. Epidemiology and outcomes of healthcare associated pneumonia: results from a large US database of culture positive pneumonia. Chest 2005;128:3854 62

  6. Outcome P<.0001 • HAP-associated mortality remains the leading cause of death among hospital-acquired infections • Crude mortality of HAP is 30-70% • Attributable mortality is 20-50% • Worse outcomes in patients with bacteremia, medical rather than surgical illness, ineffective and late antibiotic therapy. P>.05 P<.0001 Kollef MH, et al. Chest. 2005;128:3854-62.

  7. Mortality and Time of Presentation of HAP P<.001 P<.001 P = .504 50 * * 40 30 Hospital Mortality (%) 20 * 10 0 Early Onset None Late Onset *Upper 95% confidence interval Nosocomial Pneumonia Ibrahim, et al. Chest. 2000;117:1434-1442.

  8. MRSA infection Crit Care 2006:10(3):R97.

  9. HAP: Non-Vent vs. Vented Pts. Pennsylvania study on nosocomial pneumonia, 2009-2011 Davis J. The breath of hospital-acquired pneumonia: nonventilated versus ventilated patients in Pennsylvania. Focus on Infection Prevention. Pennsylvania Patient Safety Advisory. 2012;9:99-105.

  10. Etiology • Aerobic gram-negative bacteria: • P. aeruginosa, Escherichia coli, Klebsiellapneumoniae, and Acinetobacter species • Gram-positive cocci • S. pneumonia. • H. influenzae • Staphylococcus aureus (50% in ICU due to MRSA) • More common in patients with diabetes mellitus, head trauma and those hospitalized in the ICU. • Oropharyngeal commensals (viridans group streptococci, coag-negative Staph, Neisseria species and Corynebacterium) may be relevant in mostly immunocompromised patients.

  11. Results, Time of Infection • HAP: • Early onset (0-4 days): S. pneumoniae, H. influenzae • Late onset (5+ days): oxacillin resistant S. aureus, P. aeruginosa • VAP: • Early onset (0-4 days): oxacillin susceptible S. aureus, S. pneumoniae, Hemophilus sp. • Late onset (5+ days): Acinetobacter sp. and S. maltophilia

  12. Kollef MH,et al. Chest .2005;128:3854-62. Pathogens among pneumonia types

  13. Pathogens Associated With NAP P = .003 Early-onset NP 40 Late-onset NP 35 PA = P aeruginosa OSSA = Oxacillin-sensitive S aureus ORSA = Oxacillin-resistant S aureus ES = Enterobacter species SM = S marcescens 30 P = .408 25 P = .043 Nosocomial Pneumonia (%) 20 15 P = .144 P = .985 10 5 0 SM MRSA MSSA ES PA Pathogen Ibrahim, et al. Chest. 2000;117:1434-1442.

  14. Etiology • Fungal pathogens: most common is Candida and Aspergillus • Most commonly in organ transplant or immunocompromised, neutropenic patients. • Aspergillus- contaminated air ducts or local construction. • Candida- common airway colonizer and rarely requires treatment.

  15. Etiology • Viral Pathogens: low incidence in immunocompetent hosts. • Influenza A is the most common viral cause of HAP and HCAP in adults. • Risk for secondary bacterial infection “super-infection” • Streptococcus, H. influenza, Group A Streptococcus, S. aureus

  16. MDR risk factors • Host risk factors for infection with MDR pathogens include: • Treatment with antibiotics within the preceding 90 days. • Current hospitalization of >4 days • High frequency of antibiotic resistance in the community or hospital unit • Immunosuppressive disease and/or therapy • Hospitalization for >/= 2 days within the last 90 days • Severe illness • Antibiotic therapy in the past 6 months • Poor functional status

  17. ColonizationAspiration HAP

  18. Pathogenesis • Number and virulence of organisms entering the lower respiratory tract and response of the host. • microaspiration of organisms which have colonized the upper respiratory/gastrointestinal tract • Hospitalized patients tend to become colonized with organisms in the hospital environment within 48 hours. • Common mechanisms include: mechanical ventilation, routine nursing care, lack of hand washing of all hospital personnel. • Disease state also plays a role: alteration in gastric pH due to illness, certain medications, malnutrition and supplemental feedings.

  19. M

  20. Mechanisms That Lead to Oral and Oropharyngeal GNR Colonization Lam OLT, et al. Effectiveness of oral hygiene interventions against oral and oropharyngeal reservoirs of aerobic and facultatively anaaerobic graminegative bacilli. AJIC 2012;40:175-82.

  21. Which Patients Are At Risk? • Liver disease prior to and during transplantation • End-stage renal disease undergoing hemodialysis • Cardiovascular disease undergoing surgery • Abdominal cancer, head and neck cancer • Leukemia • COPD • Cerebral palsy • Asthma, stroke, chronic bronchitis, pharyngitis, HIV infection, diabetes, alcoholism, Parkinson’s Disease • Hospitalized, Institutionalized elderly individuals

  22. Management

  23. Hospital Admission • Decision to admit remain clinical • Severity scores can help. • CURB-65 criteria (>2, more-intensive treatment) • Confusion • Urea 7 mmol/L (20 mg/dL) • Increased respiratory rate >30 • low blood pressure (SBP <90 or DBP <60) • Pneumonia Severity Index (PSI) • uses demographics, the coexistence of co-morbid illnesses findings on physical examination, vital signs and essential laboratory findings

  24. PSI Score

  25. Initial Appropriate Antibiotic Therapy A Study by Kollef and Colleagues Evaluating the Impact of Inadequate Antimicrobial Therapy on Mortality 60 52* *P<.001 50 42* 40 Hospital Mortality (%) 30 24 18 20 10 0 All-Cause Mortality Infection-Related Mortality Adequate antimicrobial treatment (n=486) Inadequate antimicrobial treatment (n=169) ATS=American Thoracic Society; IDSA=Infectious Diseases Society of America. Adapted from Kollef MH et al. Chest. 1999;115:462-474. ATS/IDSA. Am J Respir Crit Care Med. 2005;171:388-416.

  26. Effect of timing on survival Fraction of total patients Time from hypotension onset (hours) Crit Care Med 2006;34:1589-96

  27. JAMA 2010 The outcome of patients with sepsis and septic shock presenting to emergency departments in Australia and New Zealand. Crit Care Resusc. 2007 Mar;9(1):8-18.

  28. Antipseudomonal cephalosporin OR Antipseudomonal carbepenem OR β-Lactam/β-lactamase inhibitor Plus Antipseudomonal fluoroquinolone OR Aminoglycoside Plus Anti MRSA Anti Legionella pneumophila and anti Viral Sever pneumonia, necrotizing or cavitary infiltrates, empyema

  29. Initial Empiric Therapy in Patients Without Risk Factors for MDR Pathogens Adapted from ATS/IDSA. Am J Respir Crit Care Med. 2005;171:401. Table 3.

  30. Linazolidvsvancomycin in pneumonia • Retrospective study suggest survival benefit than vancomycin in MRSA pneumonia (Chest 2003;124;1789-1797.) • Meta-analysis in MRSA pneumonia: non-inferior than glycopeptide(2010) • Latest randomized, double blinded trial suggest better (non-inferior) clinical success than vancomycin(2010 idsa abstract)

  31. KPC • Combination therapy • Synergistic testing • Suggested regimens include colistine plus tigecycline plus carbapenem/rifampin • Other drugs include fosfomycin, aztreonam

  32. Prevention

  33. Davis J. The breath of hospital-acquired pneumonia: nonventilated versus ventilated patients in Pennsylvania. Focus on Infection Prevention. Pennsylvania Patient Safety Advisory. 2012;9:99-105.

  34. Aspiration Precaution Bundle (APB) • Ensure bedside swallow screen completed (if failed, physician order for speech consult/NPO status • HOB elevated 30 degrees or greater • Oral care every 4 hours (brush teeth every 12 hours) • No straws • Ambulate/up in chair TID and prn • Sit upright 90 degrees for meals/snacks • Observe patient during meals (check temperature 60 minutes after meal for fever spike) • Incentive spirometry (IS), Acapella (preferred) or PEP therapy • Suction set-up in patient room • Order Aspiration Precaution on SBAR

  35. Amulti-disciplinary group comprised of nursing, speech pathology, respiratory therapy and infection prevention developed an Aspiration Precaution Bundle (APB). respiratory therapy and speech therapy participation such as oral care every four hours, Acapella or PEP therapy and bedside swallow screening. In addition, a laminated sign was created to place in the patient room

  36. Summary • HAP is a leading infection among all hospital acquired infections • HAP is associated with high mortality, long hospital stay, high economic burden • HAP is still diagnosed with relatively non specific methods • HAP etiology vary between geographical locations and each region should have real-time data • Treatment of MDR organism is posing a very significant problem • Prevention of HAP through established protocols

  37. Thank you Questions?

  38. Modifiable Risk Factors: Intubation and Mechanical Ventilation • Intubation and mechanical ventilation increase the risk of HAP 6-21 fold. • NIPPV, data shows use to avoid reintubation may be associated with more incidence of HAP. • Sedation protocols to accelerate ventilator weaning. • Reintubation increases the risk of VAP • Oral gastric and tracheal tubes rather than nasal may reduce incidence of sinusitis and subsequent lower respiratory tract infection (HAP). • Limiting use of sedative and paralytic agents that depress cough. • Keep endotracheal cuff to >20 cm H2O

  39. Modifiable Risk Factors • Strict infection control • Alcohol-based hand disinfection • Microbiologic surveillance with timely data on local MDR pathogens • Removal of invasive devices • Programs to reduce or alter antibiotic-prescribing practices

  40. Modifiable Risk Factors: Modulation of Colonization: Oral Antiseptics and Antibiotics • Oropharyngeal colonization is an independent risk factor for ICU-acquired HAP by enteric gram-negative bacteria and P. aeruginosa • Oral antiseptic chlorhexidine significantly reduced rates of nosocomial infection in post-operative patients and is routinely used in the ICU as part of “oral care”. • Selective decontamination fo the digestive tract (SDD): using non-absorbable antibiotics either orally or through GT has shown benefit in reducing HAP/VAP. However not widely used in the US due to risk for drug resistance.

  41. MDR: Stress Bleeding Prophylaxis, Transfusion, and Glucose Control • H2 blockers have shown an increased risk for VAP, risk vs. benefit for stress bleeding should be considered • Multiple studies have identified allogeneic blood products as a risk factor for post-operative pneumonia, and the time length of blood storage as another risk factor. Blood transfusion is usually limited to Hb <7 in the patient who has no active bleeding. • Hyperglycemia is an additional risk for blood stream infection, increased duration of mechanical ventilation increasing risk for HAP/VAP.

  42. Four Major Principles Underlie the Management • Avoid untreated or inadequately treated HAP, VAP or HCAP, failure to do so is a consistent factor associated with increased mortality. • Recognize the variability of bacteriology from one hospital to another, one department from another and one time period to another. • Avoid the overuse of antibiotics by focusing on accurate diagnosis, tailoring therapy and limit duration of therapy to the minimal effective period. • Apply prevention strategies aimed at modifiable risk factors.

  43. VAP vs. HAP Flora • Study of VAP and HAP pathogens for purposes of optimizing therapy • University of North Carolina Hospitals study conducted system wide, 2000-2003 • Used definitions as described by ATS • Did not include CAP or HCAP • Specimens obtained via bronchoscopy, expectorated sputum, or tracheal aspirates Weber DJ, et al. Microbiology of ventilator associated pneumonia compared with that of hospital acquired pneumonia. Infect Control Hosp Epidemiol 2007;28:825 31

  44. Results, Epidemiology588 lower respiratory therapy tract infections in 556 patientsIncidence of pneumonia: 0.37%

  45. Assessment of Non-Responders Wrong Organism Drug-resistant Pathogens: (Bacteria, Mycobacteria, Virus, Fungus) Inadequate Antimicrobial Therapy Wrong Diagnosis Atelectasis Pulmonary Embolism ARDS Pulmonary Hemorrhage Underlying Decease Neoplasm Complications Empyema or Lung Abscess Clostridium Difficile Colitis Occult Infection Drug Fever

  46. Results, PathogensPathogens isolated from 92.4% of patients with VAP and 76.6% from HAP patients

  47. Results, Time of Infection • Pathogens statistically associated with VAP: • Early onset (0-4 days): oxacillin susceptible S. aureus, S. pneumoniae, Hemophilus sp. • Late onset (5+ days): Acinetobacter sp. and S. maltophilia • HAP: • Early onset (0-4 days): only S. pneumoniae. • Late onset (5+ days): oxacillin resistant S. aureus and P.aeruginosa

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