JEREMY FISHER, PGY-3VA VASCULAR SURGERY

JULY 2011

Ventilator Associated Pneumonia

62M w/ Systolic dysfn, HTN, DMII, smoking hx, POD 7 s/p Aorto-bi-fem bypass

Kept intubated for pressor requirement post-op

Now off pressorsIncreased FiO2 from 0.40 to 0.50 o/n and

increased PEEP 5->8CXR w RML infiltrate and generalized

haziness across both lung fieldsWBC 13.5 (11.0)

What is the diagnosis? Criteria?Further studies?Treatment?What could have prevented this?

Overview

1. Diagnosis

2. Incidence and Impact

3. Treatment

4. Prevention

Overview

1. Diagnosis What is VAP? Clinical Criteria Respiratory Sampling/Cx

2. Incidence and Impact

3. Treatment

4. Prevention

What is VAP?

Pneumonia that develops in someone who has been intubated

Usually refers to those intubated >48 hours Early onset <4 days Late onset >4 days

Diagnosis of VAP

Clinical diagnosis is challenging and controversial

Suspect VAP when:CXR – new or progressive infiltrate ANDAt least 2 of fever, abnormal WBC,

purulent secretions

Obtain lower respiratory culture

Diagnosis of VAP

Clinical diagnosis is challenging and controversial

Suspect VAP when:CXR – new or progressive infiltrate ANDAt least 2 of fever, abnormal WBC,

purulent secretions

Obtain lower respiratory culture

LR 1.7; 95% CI,1.1-2.5

LR, 2.8; 95% CI, 0.97-7.9

Incidence 9.7% then likelihood 23%

LR 0.35; 95% CI,0.14-.87

Probability 3.6%

- Klompas, 2007- Review/Meta analysis,- 14 Studies

Diagnosis of VAP: CPIS Score

Diagnosis of VAP: CPIS Score

CPIS > 6

Sensitivity 72-93% Specificity 42-85%

Diagnosis of VAP: CDC Criteria

Diagnosis: Lower Respiratory Sampling

Blind Bronchial Aspirate

> 105 CFUs

Bronchoalveolar Lavage

> 104 CFUs

Mini–BALProtected Brushings

Diagnosis of VAP: Culture

Blind

Diagnosis: Lower Respiratory Sampling

Blind Bronchial Aspirate

> 105 CFUs

Bronchoalveolar Lavage

> 104 CFUs

Positive Gram StainLR 2.1 for VAP

Positive Gram StainLR 18 for VAP

If less than 50% of cells = NeutrophilsVAP very unlikely (LR 0.05-0.10)

Growth > 105 CFUs LR 9.6 for VAP

Growth > 104 CFUs “Unhelpful”

Respiratory Sampling: Comparing the Methods

-90 Trauma patients with suspected VAP

-BAL, blind aspirate, bronchoscopy brushings, blind brushings

-Compared GS and Cx-Calculated agreement between modalities (kappa values)

No statistically significant difference

in yield

Diagnosis of VAP: Summary

Clinical diagnosis is challenging and controversial

Suspect VAP when:CXR – new or progressive infiltrate ANDAt least 2 of fever, abnormal WBC, purulent secretions

Obtain lower respiratory culture+GS more meaningful w/ deeper sample+Cx >10,000 CFUs on BAL does not make diagnosis

but may guide therapy (controversial)>100,000 CFUs more convincing

Overview

1. Diagnosis

2. Incidence and Impact

3. Treatment

4. Prevention

Incidence and Impact

VAP occurs in 9-27% all intubated patients

2.1-10.7 episodes of VAP per 1000 ventilator days

Barsanti, MC, Woeltje KF. “Infection Prevention in the Intensive Care Unit.” Infect Dis Clin N Am 23 (2009) 703–725. Apr 2009.

Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit CareMed 2002;165(7):867–903.

Incidence and Impact

Patients w VAP are twice as likely to dieSignificantly longer duration of ventilation

and hospital stayAdditional $10,000-40,000

Safdar N et al. Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med. 2005 Oct;33(10):2184-93

Overview

1. Diagnosis

2. Incidence and Impact

3. Treatment Bacteriology Strategy for Antibiosis Duration of Therapy

4. Prevention

Current Recommendations

Infect Dis Clin N Am 23 (2009) 521–533

General Strategy

Starting with broad spectrum antibiotic therapy improves mortality

Choice of BS Abx regimen should be guided by institutional bacteriology

Narrow coverage when possible (Cx guided)Double coverage for those at high risk for

MDR

At Risk for MDR

Antibiotic Choice

Abx Choice Algorithm

Possible MRSA

Duration of Therapy

Reassess at 72 hours, narrow if possible, broaden if necessary

Duration not well established in literatureSome studies suggest 8 days is equivalent to

14 days (Chastre)

Overview

1. Diagnosis

2. Incidence and Impact

3. Treatment

4. Prevention

Prevention

Evidence Driven Factors to Reduce VAP- High RN to Pt ratio- Reduced use of invasive ventilation- Semirecumbent positioning- Continuous aspiration of subglottic secretions- ET cuff pressure >20 cm H2O- Silver coated ET tubes

Barsanti, MC, Woeltje KF. “Infection Prevention in the Intensive Care Unit.” Infect Dis Clin N Am 23 (2009) 703–725. Apr 2009.

Prevention

Controversial Interventions- Slightly decreased rate of VAP w/ use of

sucralfate in place of ranitidine, but increased risk of GIB (8 trials)

- Oral care w/ chlorhexidine decreases VAP rates for those intubated <48hrs

- Abx w/o diagnosis of VAP not recommended

Barsanti, MC, Woeltje KF. “Infection Prevention in the Intensive Care Unit.” Infect Dis Clin N Am 23 (2009) 703–725. Apr 2009.

REMEMBER!

1.VAP is common and costly (in lives and $)

2. New/progressive infiltrate on CXR + 2 (fever, abnormal WBC, purulent secretions) -> high clinical suspicion for VAP

3. BS abx as guided by local bacteriology, double coverage for those at high risk for MDR (esp pseudomonas)

4. Good nursing w/ HOB elevated and suctioning can reduce rates of VAP

References