Hospital-Acquired Pneumonia (HAP) & Ventilator-Associated Pneumonia (VAP) Healthcare-associated pneumonia (HCAP)

Dr. ANISH M. JOSHI

ICU REGISTRAR CRITICAL CARE DEPARTMENT

HCAP

HAP

VAP

Definitions

Healthcare-associated pneumonia (HCAP): Arises within 90 days of having been admitted to an acute care facility & pt. has resided in a nursing home or LTCF. OR Recd. I.v. antibiotics, chemo or wound care within past 30 days HAP: Arises 48 hours or more after hospital admission Is not incubating at the time of admission Ventilator-associated pneumonia (VAP): Arises 48-72 hours or more after endotracheal intubation

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

HAP: Impact
Incidence

Accounts for ~15% of all nosocomial infections (2nd most common cause of NIs after UTIs) Extra days in the hospital: 4-9 days Average extra days in ICU: 4.3 days In mechanically ventilated patients, the incidence increases with duration of ventilation. Approximately half of all episodes of VAP occur within the first 4 days of mechanical ventilation. The risk is estimated to be 3%/day during the first 5 days of ventilation, 2%/day during Days 5 to 10 of ventilation, and 1%/day after this.

Hospital Location & Relative Frequency of HAP & VAP

HAP

ICU

Non-ICU HAP 62.5%

ICU HAP 37.5%

VAP 86%

HAP 14%

Non-ICU HAP ICU HAP

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

VAP ICU HAP

INCIDENCE OF NOSOCOMIAL INFECTIONS IN COMBINED MEDICAL-SURGICAL ICUs

Medical Patients
Pneumonia UTI Bloodstream infection Lower resp. tract (not pneumonia) 30% 30%

Surgical Patients
Pneumonia UTI SSTI Bloodstream infection Lower resp. tract (not pneumonia) 33% 18% 14% 13% 6%

16%
6%

(Richards et al. Infect Control Hosp Epidemiol 2000;21:510-515)

Prevention

General
-effective infective control measure
staff education/hand wash/isolation

-survelliance
identify and quantify endemic and new MDR

Intubation and mechanical ventilation

-avoid if possible -non invesive whenever -orotracheal intubation and orogastric tube -continous aspiration of subglottic secretion -cuff pressure 20 mm of H20 -Circuit condensate -passive humidifier /HME -duration of intubation and ventilation -avoid constant sedation and paralysis -adequate staffing

Minimum transport of pt. Orotracheal Nasotracheal ET/RT

Aspiration

and feeding

- PUP 450 - Semirecumbent position especially when feeding -Enteral Vs Parenteral

Modulation Colonisation,antiseptic and antibiotic

-SDD -may reduce VAP /not effective when MDR -Prior antibiotic-reduce HAP/if inf in presence of antibiotic suggest MDR -Oral Chlorhexidine M/W

Other
-Stress ulcer prophylaxis Sucralfate Vs H2 Blocker -Transfusion restricted/leuckocyte depleted - Glycemic control

Risk Factors

Prior antimicrobial therapy in preceding 90 days Current hospitalisation of >5 days High frequency of antibiotic resistance in the community or in the specific hospital unit Presence of risk factors for HCAP: Hospitalisation for >2 days in the preceding 90 days Residence in a nursing home or extended-care facility Home infusion therapy (including antibiotics) Chronic dialysis within 30 days Home wound care Family member with MDR pathogen Immunosuppressive disease and/or therapy

Pathogenesis of HAP/VAP

Pathogenesis of HAP/VAP

Pathogenesis of VAP

Endogenous and Exogenous Sources

Causative Pathogens

Classification of HAP & VAP:

Risk Stratification
3 4 5 6
Time from Hospitalization (days)

Early-onset HAP
Time from Intubation (days)

Late-onset HAP

Early-onset VAP

Late-onset VAP

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

Early HAP/VAP
Bacteriology

Late HAP/VAP

S. pneumoniae H. influenzae
MSSA Susceptible GNB E. Coli Kleb. Pneumoniae Proteus spp. Enterobacter spp. Serratia marescens

P. aeruginosa Acinetobacter
MRSA Antibiotic resistant Enterobacteriaceae Enterobacter spp. ESBL +ve strains Kleb. Spp. Legionella pnemophila Burkholderia cepacia Aspergillus spp.
Higher attributable mortality and morbidity

Prognosis

Less severe, little impact on outcome Mortality minimal

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

Diagnosis of HAP

Diagnosis of HAP/VAP

Chest infiltrate with atleast one clinical feature

-fever -leukocytosis -purulent tracheal secretion

Noninvasive/Clinical approach

Vs.

Invasive /Quantitative culture approach

Non-invasive/Clinical
1.

CPIS (Clinical Pulmonary Infection Score)

Temperature C Points 38.5 but 38.9 1 39.0 or 36.0 2 TC, mm-3 < 4,000 or > 11,000 1 + band forms >50 % 1 Oxygenation: PaO2/FiO2, mm Hg < 250 and no evidence ARDS 2 CXR Localized infiltrate Diffuse or patchy infiltrate Progression of infiltrate Culture of tracheal aspirate Moderate or heavy growth Same pathogenic bacteria on Gram Stain 2 1 2 1

Max. Score 12 However initially when progression of infiltrate & culture report is not known max. score can be 8-10.

2.

3. 4.

5.

Most sensitive component is improvement in oxygenation

Invasive /Quantitative culture

PSB DIAGN. THRESHOLD SENSITIVITY SPECIFICITY MOST 103 66 90 SPECIFIC TRACHEAL ASPIRATE 105 TO 106
CFU/ML

BAL 104 TO 105

CFU/ML

CFU/ML

76 75 SENSITIVE

73 82 ACCURATE

More distal the sampling:

More specific but less sensitive

Lower the threshold for growth

Differential Diagnosis
Pulmonary

oedema Pulmonary Contusion & haemorrhage Pulmonary embolism Hypersensitivity pneumonitis ARDS

Initial Therapy of HAP/VAP

Management strategies summary

HAP, VAP or HCAP suspected Obtain lower respiratory tract (LRT) sample for culture (quantitative or semi-quantitative) and microscopy Unless there is both a low clinical suspicion for pneumonia and negative microscopy of LRT sample, begin empiric antimicrobial therapy using an algorithm and local microbiological data Days 2 and 3: check cultures and assess clinical response: (temperature, WBC, chest X-ray, oxygenation, purulent sputum, haemodynamic changes and organ function) Clinical improvement at 4872 hours No Cultures
Search for other pathogens, complications, other diagnoses or other sites of infection

Yes Cultures +
Adjust antibiotic therapy, search for other pathogens, complications, other diagnosis or other sites of infection

Cultures

Cultures +
De-escalate antibiotics, if possible, treat selected patients for 78 days and re-assess

Consider stopping antibiotics

ATS/IDSA Guidelines. Am J Respir Crit Care Med 2005;171:388 416

Empiric antibiotic therapy

HAP or VAP suspected (all disease severities)

Late-onset or risk factors for MDR pathogens

NO

YES

Narrow-spectrum antibiotic therapy

Broad-spectrum antibiotic therapy

ATS/IDSA Guidelines. Am J Respir Crit Care Med 2005;171:388416

Initial empiric therapy, no known risk factors for MDR pathogens, early onset and any disease severity
Ceftriaxone (2g OD ) OR Levofloxacin(750 mg OD), Moxifloxacin(400 mg OD) or Ciprofloxacin (400 mg TDS) OR Ampicillin/sulbactam( 3 g QID) OR Ertapenem (1 g OD) All i.v

Initial empiric therapy in patients with late onset or risk factors for MDR pathogens, and any disease severity
Cephalosporin OR Carbapenem OR -lactam/-lactamase inhibitor PLUS Fluoroquinolone OR Aminoglycoside
Cefepime ( 2g OD ) Ceftazidime (2 g TDS) Imipenem (500 mg QID or 1 g TDS) Meropenem ( 1 g TDS) Piperacillin/tazobactam (4.5 g QID)

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

Amikacin (20 mg/kg OD) Gentamicin or Tobramycin PLUS (7 mg/kg OD) Linezolid (600 mg/kg BD) or Vancomycin (15 mg/kg upto 1 g BD) All I.V. (if MRSA risk factors are present or there is a high incidence locally)

Factors afffecting results

Penetration ----fluroquinolone,linezolide best ----Beta lactam less Mechanism of action ---concentration dependentaminoglycoside,quinolone ---time dependent-vancomycin,Beta lactam

Post antibiotic effect for gram negative aminoglycoside,quinolone- prolong --beta lactam- no/short (except carbepenem) Beta lactam---frequent dosing Aminoglycoside,quinolone---single daily dose

Optimal antibiotic therapy

Shorten the duration from 14-21 days to 8 days unless the pathogen is not pseudomonas aeruginosa or patient has poor clinical response. Initial iv oral/enteral with good response & fning int. tract Combination therapy for MDR pathogens Cycling antibiotics within the same class may antibiotic resistance

Resolution

Microbiological --serial culture --end point-bacterial eradication,superinfection,recurrent infection,microbiological persistence --PSB -<103 cfu/ml,72 hours after starting antibiotic-Radiologicallimited value as improvement lag behind clinical detect deteriorationmultilobar,increase filtrate >50% ,cavity develop,significant pleural effusion Clinical --core temp,WBC,oxygenation

Deterioration or Nonresolution

CX
length of stay in ICU/Hosp. Expensive Necrotizing pneumonia with risk of pul. hrrage Prolonged rehabilitation due to muscle loss particluarly in elderly Death

T H A N K Y O U

Risk Factors
Co-morbid Illnesses

(contd.)
Ventilation

ICU Therapies

Injuries

Cancer COPD Chronic cardiac disease Kidney failure

CPR Corticosteroid use General surgery Neurosurgery Antacids Paralytic agents Tracheostomy RT Large-volume gastric aspiration

Burns Coma Head injury MODS ARDS

Duration of mechanical ventilation Intracuff pressure <20 cm H20 Reintubation

(Mehta RM. J Intensive Care Med 2003;18:175-88) (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)