ventilator associated pneumonia -by dr.tinku joseph

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VENTILATOR ASSOCIATED PNEUMONIA (VAP)Dr.Tinku JosephDM ResidentDepartment of Pulmonary MedicineAIMS, KochiEmail: tinkujoseph2010@gmail.com

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

Host Factors

VAP- Risk FactorsIntensive Care SettingUse of Antimicrobial AgentsContaminated handsContaminated Equipment

Colonisation

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 ??

VAP Types

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)

Incidence

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

Pathogenesis

Pathogenesis

VAP 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!!!!!

DIAGNOSIS

Clinical presentation

Clinical Pulmonary Infection Score (CPIS)

CPIS

How do we diagnose ? 2-1-2

Microbiological diagnosisATS/IDSA

Respiratory secretion sampling

Bronchoscopic methods

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

RADIOLOGIC DIAGNOSIS

INFILTRATES

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).

Treatment failure

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

De

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