HOSPITAL ACQUIRED PNEUMONIA PULMONOLOGY UNIT.pptx

hospital acquired pnuemonia

1. HOSPITAL ACQUIRED PNEUMONIA

2. PRESEN T A TI O N  Definition  Epidemiology  Risk factors  Clinical features and diagnosis  Etiology  Pathogenesis  Investigations  Treatment  COMPLICATIONS  VENTILATOR ASSOCIATED PNEUMONIA

3. DEFINITION  Pneumonia that develops in hospitalized patients more than 48 hours after admission  It is not present at admission  Ventilator associated pneumonia is a subset of hospital acquired pneumonia and is pneumonia that occurs 48 hours after endotracheal intubation and mechanical ventilation

4.  Health care associated pneumonia  Non hospitalized patient  Extensive healthcare contact  Patients receiving renal replacement therapy  Residents in long term care facilities  Patients who are receiving intravenous antibiotics or chemotherapy last 30 days  Recent admission in a hospital  Wound care at home etc

5. Epidemiology  70 % of HAP cases are acquired outside the ICU and 30% in the ICU It is considered to be the second commonest cause of nosocomial infections  It is the commonest fatal nosocomial infection  It greatly increases the duration and the cost of hospital admissions  It is a global infection

6. Risk factors  Antibiotic exposure  Old age  Severe comorbidities  Underlying immunosuppression  Colonization of the oropharynx, trachea, nasal passages, stomach by virulent organisms  Conditions that promote microaspiration or inhibit coughing  Thoracic/abdominal surgeries  Endotracheal tube insertion  CNS pathology strokes dementia altered level of consciousness  Supine position  Exposure to contaminated respiratory devices

7. CLINCAL FEATURES  Fever  Cough  Purulent sputum  Signs of chest consolidation  Tachycardia tachypnea  Deceased oxygenation  Elderly patients …  Leucocytosis/leukopenia  New infiltrate or progressive infiltrate on CXR  DIAGNOSIS  Presence of CXR findings and 2 factors suggesting infection as above  Note that establishing diagnosis can be controversial

8. Pathogenesis  Microaspiration of bacteria that colonize the oropharynx and upper airways in seriously ill patients  Seeding of the lung due to bacteraemia  Inhalation of contaminated aerosols  HAP represents an imbalance between the host defenses and the ability of microorganisms to colonize and invade the lower respiratory tract

9. Pathogens  Local Antibiograms  Most important pathogens  Enteric gram negative bacilli esp pseudomonas aeruginosa  Gram positive cocci esp MSSA MRSA  Others include Enterobacter species Klebsiella pneumoniae E coli Serratia marcescens Proteus and Acinetobacter species  MSSA Strept pneumonia and H influenzae most implicated when it develops within 4 to 7 days of admission whereas P aeruginosa MRSA and enteric gram negative organisms become more common with increasing duration of admission

10.  Risk factors for infection with multidrug resistant pathogens include  Prior intravenous antibiotic therapy past 90 days  Structural lung disease  Colonization with MDR pathogens  High prevalence in local antibiograms  Resistant organisms markedly increase mortality and morbidity  High dose corticosteroids increase risk of Legionella and pseudomonas  Chronic suppurative lung diseases such as CF and bronchiectasis increase risk of gram negative pathogens including resistance strains

11. VIRUSES  VIRUSES CAN BE A CAUSE OF HAP  Parainfluenzae  Influenzae  RSV  Sars Cov 2  Fungi can also affect immunocompromised patients

12. INVESTIGATIONS  IMAGERY  CXR or CT CHEST USS  Bronchoscopy  Blood cultures  Pleural fluid cultures  Gram stains and semiquantitative cultures of sputum samples  WBC  ECG  PULSE OXIMETRY/BLOOD GASES

13.  Prognosis  The mortality is high despite effective antibiotics  Mortality as high as 27% in non ICU HAP and over 36% in ICU HAP  Mortality may be due to underlying disease  Risk factors for increases mortality include advanced age heart failure renal disease and immunosuppression.  Good coverage improves prognosis  Resistance bacteria worsen prognosis

14. TREATMENT OF HAP  TREATMENT SHOULD BE EARLY AND SO EMPIRIC ANTIBIOTIC THERAPY IS INSTITUITED  ANTIBIOTICS chosen depend on  Local sensitivity patterns/ Local antibiograms  Patients risk factors for resistance organisms  Current recommendations emphasize use of narrower spectrum of empiric antibiotic treatment  No risk of resistant organisms use  Piperacillin/tazobactam  Cefipime  Levofloxacin  Imipenem meropenem  Reassess patient 2 to 3 days after initiation of Rx take actions based on available culture results and response

15.  Where you suspect resistance  For MRSA  Add Vancomycin/linezolid  Where you do not have local antibiograms  Triple therapy  Using 2 drugs with activity against pseudomonas and 1 drug against MRSA  An anti pseudomonal cephalosporin cefipime or ceftazidime or carbapenem or beta lactam inhibitor piperacillin/tazobactam  An anti pseudomonal fluoroquinoline or a1n a1minoglycoside (amikacin gentamicin tobramycin  Once the organism is identified drugs changed to narrowest regime possible

16.  There needs to be ventilation and haemodynamic support as needed  Ensure good oxygenation  Good hydration  Blood pressures optimal  Good nutrition  Ensure good hand hygeine

17. Not High Risk mortality, Not high Risk MSRA Not High Risk Mortality but high risk MRSA High Risk Mortality High Risk MSRA One of the following Penicillin based antipseudomonal OR Cepholosporin based antipseudomonal OR A ntip s eu d o m o nal fluoroquinoline OR carbapenem ONE ANTIPSEUDOMONAL From Column A PLUS Vancomycin OR Linezolid Two antipseudomonal from different classes Select from Column A Plus V anc o m ycin OR Linezolid

18. COMPLICATIONS  Respiratory failure  Pleural effusions/empyema1  Septic shock  Renal failure

19. CASE PRESENTATION  32 YEAR OLD HEALTHY PATIENT ADMITTED TO SURGICAL UNIT WITH MULTIPLE FRACTURES AFTER A CAR CRASH  3 DAYS AFTER ADMISSION DEVELOPS  FEVER COUGH  PURULENT SPUTUM  WORSENING DYSPNOEA  CXR SHOWS EXTENSIVE INFILTRATES RUL

20. Ventilator associated pneumonia  DEFINITION  Inflammation of the lung parenchyma caused by infectious agents not present at the time mechanical ventilation started  Pneumonia that occurs more than 48 to 72 hours after endotracheal intubation  Early VAP occurring within the first 4 days  Better prognosis  More likely to have antibiotic sensitive bacteria  Late VAP occurring 5 days or more after more likely to have resistant organisms

21.  VAP is the most common and fatal nosocomial infection of critical care.  It affects 5% to 40% of patients receiving invasive mechanical ventilation  Daily risks peak between 5 to 9 days of ventilation  VAP risk factors  Male gender  Underlying medical conditions including comorbidities and severity of illness  Higher incidence in cancer trauma COPD patients

22.  High mortality rates attached to VAP attributable mortality 9 to 13%  Mortality mainly driven by patients underlying conditions and illness severity  VAP Associated with prolonged duration of MV and prolonged ICU stay

23.  Pathophysiology  Aspiration of micro-organisms  Nasal  Pharyngeal  Gastric  Intubation procedures  Biofilm formation  Contaminated secretions  Contaminated respiratory equipment

24. RISK FACTORS  HOST FACTORS  Immunosuppression  Old age  Supine position  Duration of ventilation  Previous use of antibiotics  MICROBIOLOGIC FACTORS  Virulence  Drug resistance  Biofilm formation

25. MICROBIOLOGY  ONSET OF PNEUMONIA  Within 4 days  Etiology usually strept pneumonia MSSA H influenzae  Late VAP  Pseudomonas MRSA enterobactericae Klebsiella e coli serratia proteus enterobacter Acinetobacter  IV antibiotics last 90 days ARDS Septic shock  Pseudomonas MRSA gram negative organisms acinetobacter specie

26.  Increased colonization  Dental plaques oropharynx  Sinuses  Stomach PH  INCREASED RISK OF ASPIRATION  Altered cough reflex  Microaspiration around cuff  Impaired mucociliary clearance

27. DIAGNOSIS OF VAP  Clinical suspicion  New or progressive infiltrates  Positive microbiologic cultures from lower respiratory tract specimens  Good sputum/induced sputum  BAL  BPS  Pleural fluid culture  Blood culture  Transtracheal aspiration

28. DIFFERENTIAL DIAGNOSIS  Pulmonary oedema  Pulmonary contusion  Pulmonary hemorrhage  Atelectasis  Thromboembolic disease  ARDS  Bronchogenic carcinoma

29. BIOMARKE R S  Procalcitonin  C re a ctive protein  sTREM-1  Soluble triggering receptor expressed on myeloid cells  Generally they are not helpful in diagnosis but can be used to monitor response

30. INITIAL EMPIRIC ANTIBIOTIC THERAPY  CHOICE SHOULD BE GUIDED BY LOCAL ANTIBIOGRAMS THESE VARY FROM INSTITUITION TO INSTITUITION AND EVEN WHITHIN SAME INSTITUITION  Early appropriate broad spectrum antibiotic therapy must be given  Inappropriate therapy a risk for mortality and prolonged hospital stay  Patient factors also guide therapy  Those at risk for MDR ORGANISMS  VAP occurring after four days  IV antibiotic therapy last 90 days  Immunocompromised patients  Patients with underlying severe respiratory disease

31.  Duration of antibiotic treatment is usually for seven days  Can be longer if there is empyema lung abscess immunocompromised patients  Extending antibiotic cover can lead to antibiotic resistance strains increased costs patient harm

32. Prevention of VAP/HAP  Elevation of the head of the bed greater than 30 degrees  Daily sedation vacations and assessment of readiness to extubate  Avoiding prolonged intubation  Specially designed tracheal tubes with attached suction devices  Oral care using chlorhexidine  Taking care with peptic ulcer prophylaxis  Using a closed circuit for aspiration  Avoiding contamination of respiratory circuit  Avoiding intubation using non invasive methods of ventilation  Smooth enteric feeding  Early mobilization  INCENTIVE SPIROMETRY POST SURGERY

33. CONCLUSION  VAP remains one of the most frequent ICU acquired infections with increased mortality  Diagnosis should be on clinical, radiological and microbiological evidence  Microbiological confirmation strongly recommended for diagnosis  Antibiotics limited to 7 days  Effective management of patients who have HAP/VAP include different specialists pulmonologists critical care physicians Infectious dieases specialists cardiologists as required expert nursing care  Preventive strategies are key

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