CAP HAP

Srinagarind Med J 2010: 25 (Suppl)

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HAP, VAP and HCAP Guidelines: from Guidelines to Clinical Practice

nosocomial infection nosocomial pneumonia urinary tract infection, blood stream infection skin and soft tissue infection nosocomial pneumonia hospital acquired pneumonia (HAP)

48 ventilator associated pneumonia (VAP) 48 HAP VAP health care associated pneumonia (HCAP) 2 90 nursing home chemotherapy, wound care chronic dialysis 30

1

nosocomial pneumonia morbidity mortality 2552 nosocomial

infection 31 12 VAP 5 HAP nosocomial infection (guidelines) nosocomial pneumonia

aspiration oropharynx trachea cuff pressure endotracheal tube aspiration nasal sinus gastric content endogenous pathogens colonization inhalation exogenous pathogens health care worker ventilator circuit nebulizer biofi lms endotracheal tube ( 1)

2


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empiric antibiotic new infi ltrates 2 3 1) 38.3 oC, 2) leukocytosis ( 12,000 /) leukopenia ( 4,000 /), 3) (purulent secretion)1 69 75 Grams stain quantitative colony count semi-quantitative colonization lung infi ltrates congestive heart failure, atelectasis, pulmonary hemorrhage, pulmonary drug reaction, pulmonary thromboembolism, ARDS

clinical pulmonary infection score (CPIS)3 6 PaO2/FiO2

1 0 2 0 12 6 77 42 invasive diagnosis bronchoscopy bronchoalveolar lavage fl uid (BALF) 4 Grams stain bronchoscopy biomarkers C-reactive protein procalcitonin VAP4

I

Sources of microorganisms causing HAP and VAP

Endogenous Exogenous

Aspiration Inhalation

HAP and VAP

Oropharynx, Trachea, Nasal carriage, Sinusitis, Gastric fluids

Health care worker, Ventilatory circuits, Nebulizers, Biofilms

Blood

1 HAP VAP2


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2 early onset 5 late onset 5 1 90 5 HCAP immunosuppressive therapy late onset P.aeruginosa, K.pneumoniae (ESBL), Acinetobacter species MRSA early onset S.pneumoniae, H.infl uenzae, Methicillin-sensitive S.aureus antibiotic-sensitive enteric gram negative bacilli (E.coli, K.pneumoniae, Enterobacter species, Proteus species Serratia marcescens)1 HAP VAP HAP 21.8 1,000

(admission) VAP 28.3 5 HAP VAP A.baumannii 28.2 , Pseudomonas spp. 17.8 K.pneumoniae 7.7, MRSA 7.6 E.coli 2.85 A.baumannii

2552 HAP 0.5 1,000 (hospital day) P.aeruginosa 29.7 , A.baumannii 22.6 K.pneumoniae 19.4, MRSA 9.0, E.coli 4.5, Enterobacter spp. 4.5, Xanthomonas maltophilia 4.5, Proteus mirabilis 1.9 Serratia marcescens 1.9 VAP 13.6 1,000 (ventilator day) A.baumannii 26.9 P.aeruginosa 25 K.pneumoniae 15.4, Enterobacter spp. 8.8, MRSA 7.2, Xanthomonas maltophilia 7.2, E.coli 4.8 Serratia spp. 2.4 P.aeruginosa ceftazidime

1 The modifi ed clinical pulmonary infection score (CPIS)3

CPIS points 0 1 2Tracheal secretions Rare Abundant Abundant+purulentsChest X-ray infi ltrates No infi ltrate Diffused LocalizedTemperature, oC > 36.5 and < 38.4 > 38.5 and < 38.9 > 39 or < 36Leukocytes count, per mm3 > 4,000 and < 11,000 < 4,000 or > 11,000 < 4,000 or > 11,000 +

band form > 500PaO2/FIo2, mmHg > 240 or ARDS < 240 and no evidence

of ARDSMicrobiology (tracheal aspiration)

Negative Positive

Total score 0-12, if >6 likelihood of pneumonia


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58, piperacilin/tazobactam 72, imipenem 26, meropenem 17, netilmicin 96 colistin P.aeruginosa 99 A.baumannii A.baumannii cefoperazone/sulbactam 17, imipenem 5, meropenem 5 netilmicin 42 colistin A.baumannii 99 tigecycline A.baumannii 85 K.pneumoniae K.pneumoniae ESBL ceftriaxone 98 K.pneumoniae ESBL carbapenem imipenem meropenem 100

ATS IDSA guidelines 2 1 early onset limited spectrum ceftriaxone antipneumococcal fl uoroquinolone (levofl oxacin moxifl oxacin) ampicillin/ sulbactam ertapenem late onset board spectrum combination antipseudomonal cephalosporin (cefepime, ceftazidime) antipseudomonal carbapenem (imipenem meropenem) -lactam/ -lactamase inhibitor (piperacillin/tazobactam cefoperazone/sulbactam) antipseudomonal fl uoroquinolone (ciprofl oxacin levofl oxacin) aminoglycosides (amikacin, gentamicin tobramycin) MRSA gram-positive cocci in cluster ceftazidime 2 8 , imipenem 500 6 1 8 , meropenem 1 8 , piperacillin/tazobactam 4.5 6 , cefoperazone/sulbactam 2 3 12 , amikacin 20 //, levofl oxacin 750 , moxifl oxacin 400

, ciprofl oxacin 400 8 , vancomycin 15 / 12 linezolid 600 12

Asian guidelines Acinetobacter spp. sulbactam containing antibiotic VAP HAP6 Asian guidelines7 1. Early onset HAP: third generation cephalosporin (ceftriaxone cefotaxime), fl uoroquinolone (levofl oxacin moxifloxacin), -lactam/ -lactamase inhibitor (amoxicillin/clavulanic acid ampicillin/sulbactam), ertapenem -lactam monobactam (aztreonam) clindamycin 2. Late onset HAP: 2 third generation cephalosporin (ceftazidime cefepime), carbapenem (imipenem meropenem), -lactam/-lactamase inhibitor (piperacillin/tazobactam) fluoroquinolone (ciprofloxacin, levofl oxacin), aminoglycoside (amikacin, gentamicin, tobramycin) gram-positive cocci in duster glycopeptides (vancomycin teicoplanin), linezolid Acinetobacter spp. sulbactam containing regiments cefoperazone/sulbactam ampicillin/sulbactam fl uoroquinolone (ciprofl oxacin levofl oxacin), aminoglycoside (amikacin, gentamicin, tobramycin) 3. Early onset VAP: late onset HAP antipseudomonal cephalosporin ceftazidime fourth generation cephalosporin (cefepime cefpirome) 2 aminoglycoside fl uoroquinolone fl uoroquinolone L.pneumophila aminoglycoside aminoglycoside amikacin


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gentamicin tobramycin netilmycin sulbactam containing regimen Acinetobacter spp.

4. Late onset VAP: late onset HAP antipseudomonal cephalosporin piperacillin/tazobactam carbapenem (imipenem meropenem) P.aeruginosa Acinetobacter spp. K.pneumoniae ESBL Acinetobacter spp. sulbactam containing regimens cefoperazone/sulbactam ampicillin/sulbactam fl uoroqui-nolone (ciprofl oxacin levofl oxacin), aminogly-coside (netilmycin amikacin) fi rst-line second-line 37

continuous intravenous drip -lactam time above MIC colistin

empiric antibiotic 2 3 1,7

oxygen saturation (white blood cell count)

2

HAP VAP 7 P.aeruginosa, A.baumannii S.maltophilia 14 MRSA, P.aeruginosa , Acinetobacter spp. gram-negative bacilli ESBL 14 21 Asian guidelines 6

(de-escalating therapy)7

2 fi rst-line (1) second-line (2) Resistant pathogens Rank Antibiotic regimen

MRSA 1 Vancomycin or teicoplanin2 Linezolid or tigecycline

MDR P.aeruginosa 1 Piperacillin/tazobactam or carbapenems plus/minus aminoglycosides or fl uoroguinolones (ciprofl oxacin)

2 Polymyxin B or colistin plus/minus ciprofl oxacinMDR Acinetobacter spp. 1 Cefoperazone/sulbactam and/or tigecycline

2 Polymyxin B or colistinK.pneumoniae ESBL 1 Carbapenems or tigecycline

2 Piperacillin/tazobactamE.coli ESBL 1 Carbapenems or tigecycline

2 Piperacillin/tazobactam


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HAP VAP HAP VAP morbidity mortality HAP VAP 8 VAP9, 10 2 1. Evidence-based practice guidelines VAP - Non-invasive mechanical ventilation

- Orotracheal intubation orogastric tube nasotracheal intubation nasogastric tube nosocomial sinusitis VAP - Elevated head of the bed 30 45 85 11 8 supine 0 34 - Stress ulcer bleeding prophylaxis coagulopathy GI bleeding mortality 5 H2 blocker GI bleeding sucralfate H2 blocker sucralfate early onset VAP sucralfate late onset VAP H2 blocker

9 H2 blocker stress ulcer bleeding prophylaxis - Daily sedation interruption and weaning protocol12 daily sedation interruption 7.3 4.9 daily sedation interruption VAP self-extubation - Decontamination of oropharynx 0.2% chlorhexidine systematic review meta-analysis

oral antiseptic VAP 44 endogenous source 13 - Hand washing antiseptic alcohol hand-rub exogenous source - Monitor cuff pressure 18 25 minimal occluding pressure aspiration 2. Device-based technologies - Continuous aspiration of subglottic secretions (CASS) aspiration endogenous source VAP prolonged mechanical ventilation14 - Silver-coated endotracheal tube15 endotracheal tube internal bio-layer bacterial colonization biofi lm silver-coated endotracheal tube VAP silver-coated endotracheal tube VAP 4.8 uncoated ET tube VAP 7.5 - Ultrathin cuff endotracheal tube high-volume low-pressure cuff leakage cuff tracheal injury VAP bundle of care VAP bundle of care Institute for health care improvement (IHI) ventilator bundle of care16 VAP , GI bleeding deep venous thrombosis IHI ventilator bundle of care 4 1) elevated head of the bed 30 45 , 2) daily sedation vacations assessment for extubation, 3) peptic ulcer prophylaxis 4) deep venous thrombosis prophylaxis IHI ventilator bundle of care (adherence) bundle of care 2 3 90 100


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VAP 10/1,000 ventilator day 2 3 / 1,000 ventilator day 8 1 17, 18 ventilator bundle of care IHI ventilator bundle of care oral care 0.12% chlorhexidine 4 VAP 19 IHI ventilator bundle of care European care bundle for VAP20 5 VAP 1) ventilator circuit , 2) alcohol hand hygiene, 3) educated and trained staff, 4) sedation vacation and weaning protocol 5) oral care with chlorhexidine VAP

..2553 KKU VAP bundle of care VAP 5 1) hand washing antiseptic alcohol hand-rub, 2) elevated head of the bed 30 45 85 , 3) daily sedation interruption weaning protocol, 4) optimized of endotracheal tube cuff pressure 18 25 5) decon-tamination of oropharynx 0.2% chlorhexidine bundle of care VAP

morbidity mortality

bundle of care

1. The American Thoracic Society and the Infectious Disease Society of America. 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.

2. Rotstein C, Evans G, Born A, Grossman R, Light RB, Magder S, et al. Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumoniea in adults. Can J Infect Dis Med Microbiol 2008; 19:19-53.

3. Pugin J, Auckenthaler R, Mili N, Janssens JP, Lew PD, Suter PM. Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and non bronchoscopic blind bronchoalveolar lavage fl uid. Am Rev Respir Dis 1991; 143:1121-9.

4. Rea-Neto A, Youssef NCM, Tuche F, Brunkhorst F, Ranieri VM, Reinhart K, Diagnosis of ventilator-associated pneumonia: a systematic review of the literature. Crit Care 2008; 12:R56.

5. Chawla R. Epidemiology, etiology, and diagnosis of hospital-acquired pneumonia and ventilator-associated pneumonia in Asian countries. Am J Infect Control 2008; 36: S93-S100.

6. Lagamayo EN. Antimicrobial resistance in major pathogens of hospital-acquired pneumonia in Asian countries. Am J Infect Control 2008; 36: S101-S108.

7. Song JH and the Asian HAP working group. Treatment recommendations of hospital-acquired pneumonia in Asian countries: fi rst consensus report by the Asian HAP Working Group. Am J Infect Control 2008; 36: S83-S92.

8. Thai Clinical practice guidelines for management and prevention of adults with hospital-acquired and ventilator-associated pneumonia. The Thai Society of Critical Care Medicine Bulletin Vol 15 No.1 January February 2007.


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9. Efrati S, Deutsch I, Antonelli M, Hockey PM, Rozenblum R, Gurman GM. Ventilator associated pneumonia: current status and future recommendations. J Clin Monit Comput 2010; 24:161-8.

10. Muscedere J, Dodek P, Keenan S, Fowler R, Cook D, Hey land D, et al. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: prevention. J Crit Care 2008; 23:126-37.

11. Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogu S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia in mechanical ventilated patients: a randomised trial. Lancet 1999; 354:1851-8.

12. Kress JP, Pohlman AS, OConnor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. New Engl J Med 2000; 342:1471-7.

13. Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ 2007; 334:889.

14. Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, Saint S. et al. Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis. Am J Med 2005; 118:11-8.

15. Kollef MH, Afessa B, Anzueto A, Veremakis C, Kerr KM, Margolis BD, et al. Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia. JAMA 2008; 300:805-13.

16. Institute for Healthcare Improvement: Implement the ventilator bundle. Available from: http://www.ihi.org/IHI/Topics/CriticalCare/Intensive-Care/Changes/Implement Ventilator Bundle.htm. Assessed October 11, 2009.

17. Al-Tawfi q JA, Abed MS. Decreasing ventilator-associated pneumonia in adult intensive care units using the Institute for Healthcare Improvement bundle. Am J Infect Control 2010; 38:552-6.

18. Bird D, Zambuto A, ODonnell C, Silva J, Korn C, Burke R, et al. Decreasing Ventilator-associated pneumonia in the surgical intensive care unit. Arch Surg 2010; 145:465-70.

19. Hutchins K, Karras G, Erwin J, Sullivan KL. Ventilator-associated pneumonia and oral care: a successful quality improvement project. Am J Infect Control 2009; 37:590-7.

20. Rello J, Lode H, Cornaglia G, Masterton R, The VAP Care Bundle Contributors. A European Care bundle for prevention of ventilator-associated pneumonia. Intensive Care Med 2010; 36:773-80.

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