ventilator associated pneumonia -by dr.tinku joseph
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VENTILATOR ASSOCIATED PNEUMONIA (VAP)Dr.Tinku JosephDM ResidentDepartment of Pulmonary MedicineAIMS, KochiEmail: firstname.lastname@example.org
Ventilator-associated pneumonia (VAP) is a type of HAP that develops more than 48 to 72 hours after endotracheal intubation.Hospital-acquired (or nosocomial) pneumonia (HAP) is pneumonia that occurs 48 hours or more after admission and did not appear to be incubating at the time of admission.Definition- Know the enemy(ATS/IDSA)guidelines 2005
Healthcare-associated pneumonia (HCAP) is defined as pneumonia that occurs in a nonhospitalized patient with extensive healthcare contact, as defined by one or more of the following:Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 daysResidence in a nursing home or other long-term care facilityHospitalization in an acute care hospital for two or more days within the prior 90 daysAttendance at a hospital or hemodialysis clinic within the prior 30 days
Definition- Know the enemy(ATS/IDSA)guidelines 2005
Definition- Know the enemyTypically in studies, patients are only included if intubated greater than 48 hoursEarly onset= less than 4 daysLate onset= greater than 4 days
Endotracheal intubation increases risk of developing pneumonia by 6 to 21 foldAccounts for 90% of infections in mechanically ventilated patients
American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.
VAP- Risk Factors
VAP- Risk FactorsAge >70 years Severe IllnessUnderlying Lung DiseaseDepressed Mental StatusImmunocompromising conditionsViral Respiratory Tract InfectionTreatments Agents that increase gastric pH (H2 blockers, antacids, proton pump inhibitors)Previous antibiotic exposure, particularly to third-generation cephalosporins.Paralytic agents
VAP- Risk FactorsIntensive Care SettingUse of Antimicrobial AgentsContaminated handsContaminated Equipment
VAP- Risk FactorsColonisation
VAP- Risk FactorsMechanical ventilationTracheostomyUse of a Nasogastric TubeSupine Position
Factors that facilitate reflux & aspiration into the lower RT
VAP- Risk FactorsAbdominal or thoracic surgeryImmobilisation
Factors that impede normal Pulmonary Toilet
Why in ICU patients ??
Early v/s late VAP
VAP occurs in 10 - 65% of all ventilated patients Crit Care Clin (2002)
Incidence increases with duration of MV 3% /day for first 5days, 2%/day for 6-10days and 1%/day after 10 days.
Mortality rate is 27% &43%with antibiotic resistant organism. critical care societies collaborative(CCSCs) Mortality rate in VAP caused by Pseudomonas or Acinetobacter is as high as 76% Crit Care Med (2004)
14Risk is greatest in patients with trauma or surgery of the head, neck, thorax, or abdomen.
Increases ventilatory support requirements and ICU stay by 4.3 daysIncreases hospital LOS by 4 to 9 daysIncreases medical cost Chest 2002;122:2115 Critical Care Medicine 2005;33:2184-93 Incidence
PathogenesisBacteria enter the lower respiratory tract via following pathways:Aspiration of organisms from the oropharynx and GI tract (most common cause)Direct inoculationInhalation of bacteriaHaematogeneous spread
ASPIRATION- primary route of bacterial entry into LRT
ENDOTACHEAL TUBE Holds the vocal cords open-predispose to micro & macro aspiration of colonized bacteria from oropharynx to LRT.Leakage of secretion containing bacteria around the ETT cuff.
NGT OR OROGASTRIC TUBE Interrupt gastro-esophageal sphincter leading GI reflux and aspiration. Increase oropharyngeal colonization, stagnation of oropharyngeal and nasal secretion.Pathogenesis
Inhalation of aerosols containing bacteria : -Contaminated RT equipment -From other patients/ healthcare personnel's -Inadequate disinfection/sterilization technique -Contaminated solutions/waterDirect contact: -Cross Contamination (Hands) Pathogenesis
MDR PathogensHost risk factors for infection with MDR pathogens include :Receipt of antibiotics within the preceding 90 daysCurrent hospitalization of 5 daysHigh frequency of antibiotic resistance in the community or in the specific hospital unit.Immunosuppressive diseaseand/ortherapySevere septic shock. Patients with HCAP are at variable risk for infection due to MDR pathogens.
DiagnosisNO UNVERSALLY ACCEPTED GOLD STANDARD DIAGNOSTIC CRITERIA!!!!!
Clinical Pulmonary Infection Score (CPIS)
How do we diagnose ? 2-1-2
Respiratory secretion sampling
BAL V/S PSB
Non Bronchoscopic Methods
Bronchoscopic V/S Blind techniques
Difference between VAP and VAT
Role of biomarkers as diagnostic and prognostic markers of VAP
SOLITARY DIFFUSENEW INFILTRATES
Radiological evidence of pneumonia
THINK BEFORE LABELLING IT AS VAP!!
Radiological mimics of pneumonia in ICU patients
Chemical/Aspiration pneumonitisAtlectasis/lung collapseLVFARDSPleural effusionPulmonary embolismPulmonary hemorrhageLung contusionInfiltrative tumorRadiation PneumonitisDrug reactionCryptogenic organizing pneumonia
How will u treat VAP?
BEFORE CHOOSING ANTIBIOTIC, keep in mind on the following issues:Risk factors of the patientWas it early or late onset Virulence of organismAntibiotic resistanceCost
TREATMENT PROTOCAL Initial therapy is empiric Start when VAP is suspected, Dont delay Individualize to institution- Hospital epidemiologic data Drug cost and availability Individualize to patient- -Early onset versus Late onset of VAP -Prior antibiotic use -Underlying disease Renal, liver disease etc -Surveillance cultures -Use gram stain results if possible
Choice of antibiotic
Specific anti microbial considerations (MRSA)Linezolid or Vancomycin is a necessary first choice for antistaphylococcal coverage.Should be discontinued if MRSA is not isolated.Linezolid 600 mg twice daily intravenously (IV; or orally if or when the patient is able to receive oral medications)Vancomycin 15 to 20mg/kg(based on actual body weight) IV every 8 to 12 hours for patients with normal renal function,
Alternative to Linezolid and vancomycin -: Clindamycin (600mg IV TID)Telavancin: activity against MRSA. 10mg/kg IV OD.Other agents-: Daptomycin, Ceftaroline.Tigecycline-: It has been approved by the FDA for skin and skin structure infections and intraabdominal infections caused by MRSA
Specific anti microbial considerations (MRSA)
Specific anti microbial considerations (MSSA)If a sputum culture reveals MSSAempiric therapy for MRSA should be replaced with nafcillin (2 g IV every four hours) or oxacillin (2 g IV every four hours).
Monotherapy/ Combination therapyAvoid cephalosporins monotherapy in ICU settings -: Presence of ESBL producing Enterobacteriaceae. Resistant organism.Carbapenams-: Most reliable agent.Eg: meropneam, imipenam- cilastin, Ertapenam.Doripenam-: Not much preferred.
Specific anti microbial considerations (Gram negative pathogens)
Specific anti microbial considerations (Legionella)Patients who have diabetes mellitus, renal disease, structural lung disease, or have been recently treated with glucocorticoids may require coverage forLegionellaspp (azithromycin or a fluoroquinolone).
Specific anti microbial considerations (Anaerobes)Patients who have aspirated or had recent abdominal surgery may warrant coverage for anaerobes (clindamycin, beta-lactam-beta-lactamase inhibitor, or a carbapenem).
Specific anti microbial considerationsAntiinflammatory effects of macrolidesStudies have shown good results in VAP (faster resolution)Extended infusions: can potentially provide effective therapy for pathogens with higher minimum inhibitory concentrations (MICs), may impede the emergence of resistance, and potentially provide a pharmacoeconomic benefit.
Aerosolized antibioticsAerosolized colistin, polymyxin, or aminoglycosides may be considered as potential additional antibiotics in patients with multidrug-resistant gram-negative bacilli. Aerosolization may increase antibiotic concentrations at the site of infection and may be particularly useful for treatment of organisms that have high MICs to systemic antimicrobial agents.
VAP- Duration of treatmentThe duration of therapy should be based upon the clinical response. The standard duration of therapy in the past was 14 to 21 days in part because of a concern for difficult to treat pathogens (eg,Pseudomonasspp).
Prevention of VAP
Specific practices have been shown to decrease VAPStrong evidence that a collaborative, multidisciplinary approach incorporating many interventions is paramountIntensive education directed at nurses and respiratory care practitioners resulted in a 57% decrease in VAP Crit Care Med (2002)Prevention of VAP
Conventional Infection control Aproach