Hospital-Acquired Hospital-Acquired Pneumonia (HAP) & Pneumonia (HAP) &

Ventilator-Associated Ventilator-Associated Pneumonia (VAP) Pneumonia (VAP)

Thursday 18 April 2013Thursday 18 April 2013

Kamal Mergani, MD,FSCCM

Internal Medicine & Critical Care Consultant, Clinical Director of ICU department

Omdurman military Hospital kamalmergani@gmail.com

DefinitionsDefinitions HAPHAP > 48 hours after admission > 48 hours after admission

VAPVAP > 48–72 hours after endotracheal > 48–72 hours after endotracheal intubation intubation

HCAPHCAP hospitalized > 2 days within 90 days of the hospitalized > 2 days within 90 days of the

infectioninfection nursing home or long-term care facilitynursing home or long-term care facility recent IV antibiotic therapy, recent IV antibiotic therapy,

chemotherapy, or wound care < 30 dayschemotherapy, or wound care < 30 days attended a hospital or hemodialysis clinic attended a hospital or hemodialysis clinic

Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia. Am J Respir Crit Care Med 2005; 171: 388–416

HAP: ImpactHAP: Impact

Accounts forAccounts for ~ ~15%15% of all nosocomial of all nosocomial infections (2infections (2ndnd most common cause of NI’s most common cause of NI’s after after UTI’sUTI’s))

Number of cases per year in USNumber of cases per year in US:: ~275,000~275,000

Extra days in the hospital: 4-9 daysExtra days in the hospital: 4-9 days Average extra days in ICU: 4.3 daysAverage extra days in ICU: 4.3 days Direct cost (estimated) of excess hospital Direct cost (estimated) of excess hospital

stay = stay = $1.5$1.5 billion per year billion per year

IncidenceIncidence

Hospital Location & Hospital Location & Relative Frequency of Relative Frequency of

HAP & VAPHAP & VAP

HAPHAP14%14%

ICU ICU HAPHAP37.5%37.5%

Non-ICU Non-ICU HAPHAP62.5%62.5%

VAPVAP86%86%

Non-ICU HAPNon-ICU HAP

ICU HAPICU HAP

VAPVAP

ICU HAPICU HAP

HAPHAP ICUICU

(Kumpf G et al. J Clin Epidemiol 1998;54:495-502)(Kumpf G et al. J Clin Epidemiol 1998;54:495-502)(Lizioli A et al. J Hosp Infect 2003;54:141-148)(Lizioli A et al. J Hosp Infect 2003;54:141-148)(Richards MJ et al. Crit Care Med 1999;27:887-(Richards MJ et al. Crit Care Med 1999;27:887-892)892)

Risk Factors for Risk Factors for HAP & VAPHAP & VAP

Risk Risk FactorsFactors for for HAP/VAPHAP/VAP

Co-morbid Co-morbid IllnessesIllnesses ICU TherapiesICU Therapies InjuriesInjuries VentilationVentilation

CancerCancer Chronic Chronic

obstructive obstructive pulmonary pulmonary disease disease (COPD)(COPD)

Chronic Chronic cardiac cardiac diseasedisease

Kidney failureKidney failure

CPRCPR Corticosteroid Corticosteroid

useuse General surgeryGeneral surgery NeurosurgeryNeurosurgery AntacidsAntacids Paralytic agentsParalytic agents Prior antibiotic Prior antibiotic

therapytherapy TracheostomyTracheostomy Use of a Use of a

nasogastric tubenasogastric tube Large-volume Large-volume

gastric aspirationgastric aspiration

BurnsBurns ComaComa Head injuryHead injury Multiple organ Multiple organ

system failure system failure (MOSF)(MOSF)

Acute Acute respiratory respiratory distress distress syndrome syndrome (ARDS)(ARDS)

Duration of Duration of mechanical mechanical ventilationventilation

Intracuff Intracuff pressure pressure <20 cm H<20 cm H2200

ReintubationReintubation

(Mehta RM. J Intensive Care Med 2003;18:175-88) (Mehta RM. J Intensive Care Med 2003;18:175-88) (Patel PJ, et al. Seminar Respir Crit Care Med 2002;23:415-25)(Patel PJ, et al. Seminar Respir Crit Care Med 2002;23:415-25)

(American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416) (American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416)

Pathogenesis of Pathogenesis of HAP/VAPHAP/VAP

Pathogenesis of HAP/VAPPathogenesis of HAP/VAP

Pathogenesis of VAPPathogenesis of VAP

Endogenous and Exogenous SourcesEndogenous and Exogenous Sources

Causative Causative Pathogens Pathogens

Classification of HAP & Classification of HAP & VAP: VAP:

Risk StratificationRisk StratificationTime from Hospitalization Time from Hospitalization

(days)(days)Time from Hospitalization Time from Hospitalization

(days)(days)

Time from Intubation Time from Intubation (days)(days)

Time from Intubation Time from Intubation (days)(days)

Late-onset HAPLate-onset HAP

Early-onset VAPEarly-onset VAP Late-onset VAP Late-onset VAP

Early-onset HAPEarly-onset HAP

0000 1111 2222 3333 4444 5555 6666 7777

0000 1111 2222 3333 4444 5555 6666 7777

(American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416)(American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416)

Pathogens to Consider Pathogens to Consider When Treating HAP/VAPWhen Treating HAP/VAP

Early HAP/VAPEarly HAP/VAP Late HAP/VAPLate HAP/VAP

TimingTiming Within five days of Within five days of admission or mechanical admission or mechanical ventilationventilation

Five days or more after Five days or more after admission or mechanical admission or mechanical ventilation ventilation

BacteriologBacteriology y

S. pneumoniae S. pneumoniae

H. influenzaeH. influenzae

Methicillin-sensitive Methicillin-sensitive S. S. aureusaureus

Susceptible gram-negative Susceptible gram-negative bacteriabacteria

P. aeruginosaP. aeruginosa

AcinetobacterAcinetobacter

Methicillin-resistant Methicillin-resistant S. aureusS. aureus

Other multi-resistant Other multi-resistant organismsorganisms

Prognosis Prognosis Less severe, little impact Less severe, little impact on outcome on outcome

Mortality minimalMortality minimal

Higher attributable mortality Higher attributable mortality and morbidity and morbidity

(American Thoracic Society/IDSA. Am J Respir Crit Care Med (American Thoracic Society/IDSA. Am J Respir Crit Care Med 2005;171:388-416)2005;171:388-416)

Frequency of bacterial pathogens in HAP in Frequency of bacterial pathogens in HAP in North America: 2,712 strains (SENTRY, North America: 2,712 strains (SENTRY, Antimicrobial Surveillance Program, Jan.-Antimicrobial Surveillance Program, Jan.-June 2000)June 2000)

RankRank OrganismOrganism No. of isolates (%)No. of isolates (%)

11 S. aureusS. aureus 760 (28.0) – (43.7% 760 (28.0) – (43.7% MRSA)MRSA)

22 P. aeruginosaP. aeruginosa 543 (20.0)543 (20.0)

33 S. pneumoniaeS. pneumoniae 246 (9.1)246 (9.1)

44 Klebsiella spp.Klebsiella spp. 203 (7.5)203 (7.5)

55 H. influenzaeH. influenzae 199 (7.3)199 (7.3)

66 Enterobacter spp.Enterobacter spp. 156 (5.8)156 (5.8)

77 E. coliE. coli 105 (3.9)105 (3.9)

88 Serratia spp.Serratia spp. 96 (3.5)96 (3.5)

99 S. maltophiliaS. maltophilia 94 (3.5)94 (3.5)

(Hoban DJ et al. Diag Microbiol Infect Dis 2003;45:279-285)(Hoban DJ et al. Diag Microbiol Infect Dis 2003;45:279-285)

Major Pathogens for VAPMajor Pathogens for VAP

1.1. MRSA MRSA (14.8%)(14.8%) (32%) (32%)

2.2. Ps. aeruginosa Ps. aeruginosa (14.3%)(14.3%) (29%) (29%)

3.3. other Staph species other Staph species (8.8%)(8.8%) (23%) (23%)

4.4. K pneumoniae K pneumoniae (3.3%)(3.3%) (23%) (23%)

5.5. Enterobacter Enterobacter (3.3%)(3.3%) (8%) (8%)

6.6. E coli E coli (3.0%)(3.0%) (25%) (25%)

7.7. Acinetobacter Acinetobacter (2.0%)(2.0%) (50%) (50%)8.8. Negative cultureNegative culture (37%) (37%) (36%) (36%)

Prevalence Mortality

Diagnosis of HAP/VAP

Clinical approach

Vs.

Invasive approach

Non-invasive Strategy for Non-invasive Strategy for Diagnosing HAP/VAPDiagnosing HAP/VAP

Clinical approach:Clinical approach: New lung infiltrateNew lung infiltrate

new onset fever, leukocytosis or purulent new onset fever, leukocytosis or purulent sputumsputum

non-quantitative bacterial analysis of non-quantitative bacterial analysis of endotracheal aspirateendotracheal aspirate

Drawback Drawback –– relatively non-specific for HAP relatively non-specific for HAP Heyland et al. demonstrated adequacy of Heyland et al. demonstrated adequacy of

clinical criteria for VAP diagnosis in RCT (clinical criteria for VAP diagnosis in RCT (BAL BAL with quantitation vs. non-quantitative with quantitation vs. non-quantitative endotracheal aspirate):endotracheal aspirate): no difference in 28 d no difference in 28 d mortality or LOS in ICU or hospitalmortality or LOS in ICU or hospital

(ATS, Am J Respir Crit Care Med 1996;153:1711-1725)(ATS, Am J Respir Crit Care Med 1996;153:1711-1725)

0

10

20

30

40

50

60

70

80

28dMortality

TargetedTherapy

DaysWithout

Antibiotics

OrganDysfunction

Score

LOS in ICU

BALETA

Diagnosis of VAP in the ICU:Quantitative BAL vs. Nonquantitative Endotracheal Aspirate (ETA)

PrimaryPrimaryOutcomOutcom

ee

Secondary OutcomesSecondary Outcomes

Resp

on

se

Resp

on

se

18.9%18.9%18.4% *18.4% *

74.2%74.2% 74.6%*74.6%*

10.4d10.4d 10.6d*10.6d* 12.3d12.3d 12.2d*12.2d*8.38.3 8.6*8.6*

(Canadian Critical Care Trials Group. NEJM 2006;355:2619-2630)(Canadian Critical Care Trials Group. NEJM 2006;355:2619-2630)

* = NS* = NS

Initial Therapy of Initial Therapy of HAP/VAPHAP/VAP

We have new 2012/2013 septic shock We have new 2012/2013 septic shock guidlienesguidlienes

Kollef MH et al. Chest 2006

Mean Mortality Rates in Mean Mortality Rates in Patients Patients with CAP, HCAP, HAP and with CAP, HCAP, HAP and VAPVAP

Kollef MH et al. Epidemiology and Outcomes of Health-care–Associated Pneumonia: Results From a Large US Database of Culture-Positive Pneumonia. Chest 2005;128:3854-3862

10.0

19.818.8

29.3

0

5

10

15

20

25

30

Mo

rta

lity

Ra

te (

% P

ati

en

ts)

CAP(n=2221)

HCAP(n=988)

HAP(n=835)

VAP(n=499)

P > 0.05

P < 0.0001

P < 0.0001

How Wrong Is Our Initial How Wrong Is Our Initial Antibiotic Treatment?Antibiotic Treatment?

Mortality Associated With Mortality Associated With Initial Appropriate Therapy In Initial Appropriate Therapy In Critically Ill Patients With Critically Ill Patients With Serious Infections in the ICUSerious Infections in the ICU

0% 20% 40% 60% 80% 100%

Luna, 1997

Ibrahim, 2000

Kollef, 1998

Kollef, 1999

Rello, 1997

Alvarez-Lerma,1996 Initial appropriatetherapy

Mortality*

ICUICUVAPVAP

15-40% Die from 15-40% Die from Serious infections Serious infections despite appropriate despite appropriate

antibioticsantibiotics

Mortality Associated With Mortality Associated With Initial Inadequate Therapy In Initial Inadequate Therapy In Critically Ill Patients With Critically Ill Patients With Serious Infections in the ICUSerious Infections in the ICU

0% 20% 40% 60% 80% 100%

Luna, 1997

Ibrahim, 2000

Kollef, 1998

Kollef, 1999

Rello, 1997

Alvarez-Lerma,1996 Initial appropriatetherapy

Initial inadequatetherapy

*Mortality refers to crude or infection-related mortalityAlvarez-Lerma F et al. Intensive Care Med 1996;22:387-394.Ibrahim EH et al. Chest 2000;118L146-155.Kollef MH et al. Chest 1999; 115:462-474Kollef MH et al. Chest 1998;113:412-420.Luna CM et al. Chest 1997;111:676-685.Rello J et al. Am J Resp Crit Care Med 1997;156:196-200.

Mortality*

ICUICUVAPVAP

TimingTiming

TimingTiming

THE Message Time is life

Critical Influence of the Time to Critical Influence of the Time to 1st Antibiotic Dose on Mortality in 1st Antibiotic Dose on Mortality in Septic ShockSeptic Shock

Patient survival with delayed antibiotic administration in septic shock

5%

39%

48%50%

58%

71%

33%

10%

0%

20%

40%

60%

80%

100%

0 5 10 15 20 25 30 35 40

Time to first appropriate antibiotic dose (hour)

Pe

rce

nt

Su

rviv

al

Kumar et al. HSC and St. Boniface General Hospital. August 2003

N = 1004 patients

Every one-hour delay… you drop survival by 7.5%

Risk Factors for Multidrug-Risk Factors for Multidrug-Resistant (MDR) Pathogens Resistant (MDR) Pathogens Causing HAP, HCAP and VAPCausing HAP, HCAP and VAP

Antimicrobial therapyAntimicrobial therapy in preceding 90 days in preceding 90 days

Current Current hospitalization of hospitalization of ≥ ≥ 5 days5 days High frequency of antibiotic resistance in the community or in the specific High frequency of antibiotic resistance in the community or in the specific

hospital unithospital unit

Risk factors for Risk factors for HCAPHCAP::

Hospitalization for >2 days in the preceding 90 daysHospitalization for >2 days in the preceding 90 days Residence in a nursing home or extended care facilityResidence in a nursing home or extended care facility Home infusion therapy (including antibiotics)Home infusion therapy (including antibiotics) Chronic dialysis within 30 daysChronic dialysis within 30 days Home wound careHome wound care Family member with multidrug-resistant pathogenFamily member with multidrug-resistant pathogen

Immunosuppressive disease and/or Immunosuppressive disease and/or therapytherapy

Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia. Am J Respir Crit Care Med 2005; 171: 388–416

Why Do We Need Why Do We Need Combination Therapy?Combination Therapy?

Achieve synergyAchieve synergy**

Prevent emergence of resistancePrevent emergence of resistance****

Better chance to initial appropriate Better chance to initial appropriate

therapytherapy* Paul M et al: Beta lactam monotherapy versus beta lactam-aminoglycoside combination therapy for sepsis in immunocompetent patients: Systematic review and meta-analysis of randomised trials. BMJ 2004; 328:668 ** Bliziotis IA et al: Effect of aminoglycoside and beta-lactam combination therapy

versus beta-lactam monotherapy on the emergence of antimicrobial resistance: A meta-analysis of randomized, controlled trials. Clin Infect Dis 2005; 41:149

Crit Care Med2007; 35:1888–1895

Pseudomonas VAP Pseudomonas VAP % Appropriate Therapy % Appropriate Therapy

57

91

0

25

50

75

100

Appropriate %

Monotherapy Combined therapy

Garnacho-Montero et al. CCM 2007

Pseudomonas VAP Pseudomonas VAP Mortality Mortality Mono vs Combination Mono vs Combination Therapy Therapy

72.5

33.3 34

0

25

50

75

100

Hospital Mortality %

InapproriateTherapy

ApproriateCombined

AppropriateMonotherapy

Garnacho-Montero et al. CCM 2007

How Long Should We How Long Should We Treat VAP?Treat VAP?

7, 14, 21 days7, 14, 21 days

JAMA. 2003;290:2588-2598

Conclusions Comparable clinical effectiveness

The 8-day group had less antibiotic use

Initial empiric therapy, Initial empiric therapy, no known no known risk factorsrisk factors for MDR pathogens, for MDR pathogens, early onsetearly onset and any disease and any disease severityseverity

CeftriaxoneCeftriaxone

(2g OD )(2g OD )

OROR

LevofloxacinLevofloxacin(750 mg OD), (750 mg OD),

MoxifloxacinMoxifloxacin(400 mg OD)(400 mg OD)

or or CiprofloxacinCiprofloxacin (400 mg TDS) (400 mg TDS)

OROR

Ampicillin/sulbactamAmpicillin/sulbactam( 3 g QID)( 3 g QID)

OROR

Ertapenem Ertapenem (1 g OD)(1 g OD)

All i.vAll i.v

Initial empiric therapy in patients with Initial empiric therapy in patients with late onset or risk factorslate onset or risk factors for MDR for MDR pathogens, and any disease severitypathogens, and any disease severity

CephalosporinCephalosporin

OR OR CarbapenemCarbapenem

OR OR

ββ-lactam/-lactam/ββ-lactamase inhibitor-lactamase inhibitor

PLUSPLUS

FluoroquinoloneFluoroquinolone OR OR

AminoglycosideAminoglycoside PLUS PLUS

Linezolid Linezolid (600 mg/kg BD)(600 mg/kg BD)

or Vancomycinor Vancomycin (15 mg/kg upto 1 g BD) (15 mg/kg upto 1 g BD)(if MRSA risk factors are present or (if MRSA risk factors are present or

there is a high incidence locally)there is a high incidence locally)

CefepimeCefepime ( 2g OD ) ( 2g OD ) Ceftazidime Ceftazidime (2 g TDS)(2 g TDS)

Imipenem Imipenem (500 mg QID or 1 g TDS)(500 mg QID or 1 g TDS) Meropenem Meropenem ( 1 g TDS)( 1 g TDS)

Piperacillin/tazobactam Piperacillin/tazobactam (4.5 g QID)(4.5 g QID)

Ciprofloxacin Ciprofloxacin (400 mg TDS)(400 mg TDS) Levofloxacin Levofloxacin (750 mg OD)(750 mg OD)

Amikacin Amikacin (20 mg/kg OD)(20 mg/kg OD)

Gentamicin or TobramycinGentamicin or Tobramycin

(7 mg/kg OD)(7 mg/kg OD)

All I.V.All I.V.

Deterioration or Nonresolution

VAP PreventionVAP Prevention

HOB ElevationHOB Elevation

HOB at 30-45HOB at 30-45ºº

CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS / IDSA Guidelines for VAP 2005ATS / IDSA Guidelines for VAP 2005

HOB Elevation Leads to HOB Elevation Leads to Significant Deduction in Significant Deduction in VAPVAP

Dravulovic et alDravulovic et al. . Lancet Lancet

1999;354:1851-18581999;354:1851-1858

0

5

10

15

20

25

% V

AP

Supine HOB Elevation

Is HOB Elevation Done?Is HOB Elevation Done?

Despite effectiveness Despite effectiveness

of HOB elevation,of HOB elevation,

compliance is poorcompliance is poor..

Grap et al. Grap et al. Am J Crit CareAm J Crit Care 1999;8:475-480 1999;8:475-480 Grap et al. Grap et al. Am J Crit CareAm J Crit Care 2005;14:325- 2005;14:325-

332332

0

20

40

60

% w

ith

HO

B E

levat

ion

0 to 20

21 to 30

31 to 40

> 40

Degrees ofHOB Elevation

Patient Turning and Patient Turning and Rotational TherapyRotational Therapy

Review of 11 randomized, controlled studies Review of 11 randomized, controlled studies (1073 patients)(1073 patients) All rotational therapies includedAll rotational therapies included 48% reduction in risk of developing pneumonia48% reduction in risk of developing pneumonia Shorter ICU stay (decrease of 2.1 days)Shorter ICU stay (decrease of 2.1 days) No difference in mortalityNo difference in mortality Kinetic therapy more effective than CLRTKinetic therapy more effective than CLRT Crit Care Med (2002)Crit Care Med (2002)

CDC does not have a current recommendation for CDC does not have a current recommendation for routine use of kinetic therapy for prevention of routine use of kinetic therapy for prevention of pneumonia pneumonia CDC (2003)CDC (2003)

Patient Turning…Patient Turning…

Rotational therapy is beneficial for Rotational therapy is beneficial for patients at high risk for atelectasis and patients at high risk for atelectasis and pneumonia, including patients who are:pneumonia, including patients who are: sedated and ventilated > 3 – 4 dayssedated and ventilated > 3 – 4 days difficult to turndifficult to turn have head injuryhave head injury in tractionin traction

When rotational beds are not used, When rotational beds are not used, turn turn at least q 2 hoursat least q 2 hours

Continuous Removal of Subglottic Continuous Removal of Subglottic Secretions Secretions

Use an ET tube with Use an ET tube with continuous suction continuous suction through a dorsal through a dorsal lumen above the cuff lumen above the cuff to prevent drainage to prevent drainage accumulation. accumulation.

Dezfulian et al. Am J Med 2005;118:11-Dezfulian et al. Am J Med 2005;118:11-

18 (meta-analysis18 (meta-analysis))CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS / IDSA Guidelines for VAP 2005

Continuous Removal of Continuous Removal of Subglottic Secretions Subglottic Secretions

ET tubes with an additional lumen for ET tubes with an additional lumen for the removal of subglottic secretions the removal of subglottic secretions have been found to decrease VAP in have been found to decrease VAP in some studies by as much as some studies by as much as 20 to 40%20 to 40%

Extra cost of the tubes will more than be Extra cost of the tubes will more than be paid for by the decrease in VAP costs.paid for by the decrease in VAP costs.

Dezfulian et al. Am J Med 2005;118:11-18 (meta-analysisDezfulian et al. Am J Med 2005;118:11-18 (meta-analysis))

VAP Reduction with ET VAP Reduction with ET Suction Suction Above the Cuff Above the Cuff

0

5

10

15

20

Perc

ent (

%)

No Suction Suction

Smulders et al. Chest;121:858-862

Subglottal SuctioningSubglottal Suctioning

Should be done using a 14 Fr sterile Should be done using a 14 Fr sterile suction catheter:suction catheter: Prior to ETT rotationPrior to ETT rotation Prior to lying patient supinePrior to lying patient supine Prior to extubationPrior to extubation

SuctioningSuctioning SET UPSET UP YANKAUER STORAGEYANKAUER STORAGE

ETT SUCTIONING ETT SUCTIONING (open v closed)(open v closed)

16 trials 16 trials (n=1684)(n=1684)

Neither Neither closed open or closed closed open or closed

suction suction systems had an effect systems had an effect

on risk of VAP or mortalityon risk of VAP or mortality

Subirana Subirana

(2007)(2007)

CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004

Frequency ofFrequency of Equipment Changes Equipment Changes

VentilatorVentilator

TubingTubing

AmbuAmbu

BagsBags

Inner Inner Cannulas Cannulas of Trachsof Trachs

No Routine

Changes

BetweenPatients

Not Enough

Data

The The MallinckrodtMallinckrodt® ® Hi-Lo EvacHi-Lo Evac® endotracheal ® endotracheal tube has been clinically proven to reduce VAP by tube has been clinically proven to reduce VAP by up to up to 59%59%

Can we justify the higher cost of the newer tubes?Can we justify the higher cost of the newer tubes? When compared to the old generation When compared to the old generation

(leaky) tubes without subglottic suction, (leaky) tubes without subglottic suction, which cost about which cost about $2$2 each, and each, and considering that each new case of VAP considering that each new case of VAP leads to an increased estimated cost of leads to an increased estimated cost of approximately approximately $5,000 to $26,000$5,000 to $26,000

Mahul Ph, Auboyer C, Jospe R, et al. Mahul Ph, Auboyer C, Jospe R, et al. Prevention of nosocomial pneumonia in intubated patients: respective role of mechanical subglottic secretions drainage and stress ulcer prophylaxis. . Intensive Care MedicineIntensive Care Medicine. 1992;18:20-25.. 1992;18:20-25.

Rello J, Ollendorf DA, et al. Rello J, Ollendorf DA, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large U.S. database. . ChestChest. 2002;122:2115-2121. . 2002;122:2115-2121.

HandwashingHandwashing

What role does handwashing playin nosocomial pneumonias?

Albert, NEJM 1981; Preston, AJM 1981; CDC Guideline for Prevention of Healthcare Associated

Pneumonias 2004

New guideline developed by the Centers for New guideline developed by the Centers for Disease Control and Prevention (CDC) and Disease Control and Prevention (CDC) and infection control organizations infection control organizations recommends recommends that healthcare workers use an alcohol-that healthcare workers use an alcohol-based handrub (a gel, rinse or foam) to based handrub (a gel, rinse or foam) to routinely clean their hands between patient routinely clean their hands between patient contacts, as long as hands are not dirty.contacts, as long as hands are not dirty.

Oral CareOral Care

Role of oral care, colonization of Role of oral care, colonization of the oropharynx, and VAP unclear the oropharynx, and VAP unclear ..

Dental plaque may be involved Dental plaque may be involved as a reservoiras a reservoir

Limited research on impact of Limited research on impact of rigorous oral care to alter VAP rigorous oral care to alter VAP ratesrates

CDC Guideline for Prevention of Healthcare Associated Pneumonias

2004Grap M. Amer J of Critical Care 2003;12:113-119.

Daily Sedation vocationDaily Sedation vocation

Daily “Sedation Vacation” and Daily “Sedation Vacation” and Daily Assessment of Readiness Daily Assessment of Readiness to Weanto Wean Correlated with Correlated with reduction in rate of VAPreduction in rate of VAP Sedation vacation results in significant Sedation vacation results in significant

reduction in reduction in time on mechanical time on mechanical ventilationventilation

Duration of mv decreased from 7.3 days Duration of mv decreased from 7.3 days to 4.9 days-study by Kress et al. NEJM to 4.9 days-study by Kress et al. NEJM 20002000

Weaning is easier when patients are Weaning is easier when patients are able to assist themselves at extubation able to assist themselves at extubation with coughing and control of secretionswith coughing and control of secretions

HME v HEATED CIRCUITSHME v HEATED CIRCUITS

>20 studies in past twenty years >20 studies in past twenty years

Contradictory but the largerContradictory but the larger trials show no statisticaltrials show no statistical differencedifference

However > 5days ventilated However > 5days ventilated reduced reduced

patency in ETT with HMEpatency in ETT with HME

Jaber et al (2004)Jaber et al (2004)

CONCLUSION: CONCLUSION: Patients receiving a Patients receiving a silver-coated silver-coated endotracheal tube endotracheal tube had a statistically had a statistically significant reduction significant reduction in the incidence of in the incidence of VAP and delayed VAP and delayed time to VAP time to VAP occurrence occurrence compared with those compared with those receiving a similar, receiving a similar, uncoated tube ,uncoated tube ,

Pedro Caruso, MD, PhD; Silvia Denari, PhD; Soraia Pedro Caruso, MD, PhD; Silvia Denari, PhD; Soraia A. L. Ruiz, RT; Sergio E. Demarzo, MD, PhD;Daniel A. L. Ruiz, RT; Sergio E. Demarzo, MD, PhD;Daniel Deheinzelin, MD, PhDDeheinzelin, MD, PhD

Crit Care Med Crit Care Med 2009 Vol. 37, No. 2009 Vol. 37, No. 11

The relative risk reduction of VAP in the The relative risk reduction of VAP in the saline instillation group was saline instillation group was ▼▼54%54% (95% (95% confidence interval [CI] 18%–74%) and confidence interval [CI] 18%–74%) and the the number needed to treat was number needed to treat was 88 (95% (95% CI 5–27).CI 5–27).

The incidence density and proportion of microbiological proven VAP were significantly higher in the control group(Table 3). The rate of clinically suspected VAP was similar in both groups

PLEASE NOTE ???PLEASE NOTE ???

You have to teach the You have to teach the nurses again and again , nurses again and again ,

rather than simply rather than simply putting rules and putting rules and

protocols.protocols.

EDUCATION EDUCATION PROGRAMMESPROGRAMMES

Demonstrated to reduce Demonstrated to reduce

incidences of VAP by +/- 50%incidences of VAP by +/- 50%

Apisarnthanarak et al (2007); Zack et al (2002)Apisarnthanarak et al (2007); Zack et al (2002)

Ventilator Ventilator BundleBundle

Preventive MeasuresPreventive Measures

Avoid prolonged nasal intubationAvoid prolonged nasal intubation Suction secretions Suction secretions Chlorexidine oral rinsesChlorexidine oral rinses Semi-recumbent position( 30-45Semi-recumbent position( 30-45°head °head

elevation)elevation) Do not change ventilator circuits Do not change ventilator circuits

routinely more often than every 48 routinely more often than every 48 hourshours

Drain and discard tubing condensateDrain and discard tubing condensate Use sterile water for respiratory Use sterile water for respiratory

humidifying deviceshumidifying devices Subglottic secretions drainageSubglottic secretions drainage

DEC 2011 MV course

2013 Critical care 2013 Critical care symposium??symposium??

THANKS FOR YOUR ATTENTION