Ventilator associated pneumonia VAP

Ventilator associated pneumonia

1. Ventilator Associated Pneumonia ( VAP) Abdelrahman Al- daqqa 12/13/2015 1

2. What is VAP? A Nosocomial pneumonia associated with mechanical ventilation (either by Endotracheal tube or Tracheostomy) that develops within 48 hours or more of hospital admission and which was not present at the time of admission. National institute of health excellence (NICE)-2007 center for disease control and prevention 12/13/2015 2

3. EPIDEMIOLOGY Hospital acquired pneumonia (HAP) is the second most common hospital infection. VAP is the most common intensive care unit (ICU) infection . 90% of all nosocomial infections occurring in ventilated patients are pneumonias . Added costs of $40,000 - $50,000 per stay 12/13/2015 3

4. Early–Onset Pneumonia (< 96 hours of intubation or ICU admission) Community-acquired Pathogens: Streptococcus pneumoniae Haemophilus influenzae Staphylococcus aureus Antibiotic-sensitive TYPES-- 12/13/2015 4

5. Late-Onset Pneumonia (> 96 hours of intubation or ICU admission) Hospital-acquired Pathogens: Pseudomonas aeruginosa Methicillin resistant Staphylococcus aureus (MRSA) Acinetobacter Enterobacter Antibiotic-resistant TYPES-- 12/13/2015 5

6. INCIDENCE 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) 12/13/2015 6

7. Cont… VAP Increases ventilatory support requirements and ICU stay by 4.3 days Increases hospital LOS by 4 to 9 days Increases medical cost Chest 2002;122:2115 Critical Care Medicine 2005;33:2184-93 12/13/2015 7

8. RISK FACTORS 12/13/2015 8

9. PATHOGENESIS Bacteria enter the lower respiratory tract via following pathways: Aspiration of organisms from the oropharynx and GI tract (most common cause) Direct inoculation Inhalation of bacteria Haematogeneous spread 12/13/2015 9

10. HOW DO WE DIAGNOSE? 2-1-2 Radiographic evidence x 2 consecutive days New, progressive or persistent infiltrate Consolidation, opacity, or cavitation Clinical sings At least 1 of the following: Fever (> 38 degrees C) with no other recognized cause Leukopenia (< 4,000 WBC/mm3) or leukocytosis (> 12,000 WBC/mm3) At least 2 of the following: New onset of purulent sputum or change in character of secretions New onset or worsening cough, dyspnea, or tachypnea Rales or bronchial breath sounds Worsening of gas exchange ( ↓ sats, P:F ratio < 240, ↑ O 2 req.) 12/13/2015 10

11. CONT… Microbiological criteria (optional ) At least one of the following : Positive growth in blood culture not related to another source of infection. Positive growth culture pleural fluid. Bronchoaleveolar lavage > 105colony forming units/ml. sensivity &specificity 42-93% &45-100% Protected specimen brushing >103cfu/ml (33-100% & 50-100%) chest.Apr2000;117(4suppl2):198-2002) Histopathological evidence of pneumonia 12/13/2015 11

12. Cont-- RADIOLOGICAL FINDING AND 2 CLINICAL CRITERIA SENCIVITY OF DIAGNOSING VAP IS 69% AND THE SPECIFICITY IS 75% SAMPLING OF RESPIRATORY SECREATION can be obtained from distal or proximal airway however the sensivity and specificity is more with distal airway sample(Bronchoalveolar lavage(BAL) , Protected specimen brush sampling(PAB ). ABSENCE OF RADIOLOGICAL FINDING HELPFUL FOR EXCLUDING THE DIAGNOSIS OF VAP 12/13/2015 12

13. A new streamlined surveillance defintion for ventilator-associated pneumonia Any one of the following 1. Opacity, infiltrate, or consolidation that appears, evolves, or persists over 72 hrs 2. Cavitation Any one of the following 1. Temperature 100.4°F within past 24 hrs 2. White blood cell 4,000 or 12,000 white blood cells/mm3 within past 24 hrs Both of the following 1. Two days of stable or decreasing daily minimum FIO2 followed by increase in daily minimum FIO2 15 points sustained for 2 calendar days OR 2 days of stable or decreasing daily minimum positive end-expiratory pressure followed by increase in daily minimum positive end-expiratory pressure by 2.5 cm H2O sustained for 2 calendar days 2. Gram-negative stain of respiratory secretions with moderate (2+) or more neutrophils per low power field within 72 hrs. Critical care med 2012 vol.40,no.1 12/13/2015 13

14. TREATMENT GENERAL APPROACH FOR INFECTION CONTROL ANTIBIOTICS- Selection of antibiotics: Early onset of VAP and no risk for MDR - Cefrioxone, fluroquinolones, ampicillin-sublactum Late onset of VAP and risk for MDR- Antipseudomonal cephalosporin(cfepime,ceftazidime) Carbapenems(imipenem,meronem), Beta lactam/betalactamase inhibitors- piperacillin-tazobactam Amonoglycocides with vancomycine,linezoid ANTIBIOTCS TO BE ADJUSTED FURTHER ON THE BASIS OF CULTURE REPORT 12/13/2015 14

15. Risk Factors for drug resistance ABX in last 14 days Prior culture with MRO Immunocompromised Chronic primary lung pathology Acute or long term care hospitalization within 14 days Tracheostomy for > 5 day 12/13/2015 15

16. DURATION OF TREATMENT - Depends on severity, - Time to clinical response and micro organism response - Isolation of microorganism - Longer duration >14-21days risk of toxicity and resistance - Shorter duration<7days- risk of recurrence - standard duration of treatment 7-14 days - Longer durtion 14-21 days may be indicated in Multilobular involvement, cavitation, gram-ve necrotising pneumonia, isolation of Pseudomonas, Acnetobacter 12/13/2015 16

17. Further inpatient care About 30% of pts. Fail to respond- 12/13/2015 17

18. EFFECT OF VAP BUNDLE CARE 12/13/2015 18 PREVENTION

19. Care Bundle A care bundle is …... “A systematic method of measuring and improving clinical care processes based on groups of care elements for particular diagnoses and procedures” NHS Modernization Agency 12/13/2015 19

20. Ventilator Associated Pneumonia Care Bundle -Evidence Based Practices Head Of Bed elevated to 30˚-45˚ Daily sedation vacation &daily assessment of readiness to wean DVT Prophylaxis Stress Ulcer Prophylaxis Subglottic secretion drainage Daily mouth care with chlorhexidine 12/13/2015 20

21. 1.HOB UP 30 DEGREES OR HIGHER Recommended elevation is 30-45 degrees If semi-recumbent or supine 34% incidence VAP ↑ HOB → ↓risk of aspiration of gastrointestinal contents ↓risk of aspiration of oropharyngeal secretions ↓risk of aspiration of nasopharyngeal secretions ↑HOB improves patients’ ventilation Supine patients have lower spontaneous tidal volumes on PS than those seated in upright position ↑HOB may aid ventilatory efforts and minimize atelectasis 12/13/2015 21

22. HOB Elevation > 30 Degrees on all Intubated Ventilated Patients Contraindications Hypotension MAP <70 Tachycardia >150 CI <2.0 Central line procedure Posterior circulation strokes Cervical spine instability use reverse trendelenburg Some femoral lines ie: IABP no higher than 30 degrees use reverse trendelenburg Increased ICP, No higher than 30 degrees avoid hip flexion Proning 12/13/2015

23. 2.Daily “Sedation Vacation” and Daily Assessment of Readiness to Wean Correlated with reduction in rate of VAP Sedation vacation results in significant reduction in time on mechanical ventilation Duration of mv decreased from 7.3 days to 4.9 days-study by Kress et al. (NEJM 2000) Weaning is easier when patients are able to assist themselves at extubation with coughing and control of secretions 12/13/2015 23

24. Conti…. Allow the patient to wake. If the patient is co-operative and able to understand commands leave the sedation off. Distressed or agitated patients require re-sedating. Administer boluses as appropriate to achieve safety . 24 12/13/2015

25. 3.Peptic Ulcer Disease (PUD) Prophylaxis It is an appropriate intervention in all sedentary patients Critically ill intubated patients lack the ability to defend their airway Decreasing pH of gastric contents may protect against greater pulmonary inflammatory response to aspiration of gastrointestinal contents 25 12/13/2015

26. More on PUD Prophylaxis Surviving Sepsis Campaign Guidelines reviewed literature on PUD prophylaxis: “ H2 receptor inhibitors are more efficacious that sucralfate and are the preferred agents. Proton Pump Inhibitors have not been assessed in direct comparison with H2 receptor antagonists and, therefore their relative efficacy is unknown. They do demonstrate equivalency in ability to increase gastric pH.” 26 12/13/2015

27. 4.Deep Vein Thrombosis (DVT) Prophylaxis Higher incidence of DVT in critical illness Risk of venous thromboembolism is reduced if prophylaxis is consistently applied TARGET: patients undergoing surgery, trauma patients, acutely ill medical patients, and ICU patients 27 12/13/2015

28. 5.Subglottal Suctioning Should be done using a 14 Fr sterile suction catheter: Prior to ETT rotation Prior to lying patient supine Prior to extubation 28 12/13/2015

29. Suctioning In line suction: Maintain closed system Use separate suction tubing Normal saline: Should not be routinely used to suction pts Causes desaturation Does not increase removal of secretions Can potentially dislodge bacteria Should be used to rinse the suction catheter after suctioning 29 12/13/2015

30. Suctioning 30 12/13/2015

31. Best Practices to Achieve a High Level of Compliance in ICUs Daily Multi-disciplinary Rounds including: Head Nurse(Unit in-charge) Reg.Nurse assigned to patient Clinical Pharmacist / Pharmacy Residents Infection Control Specialist Respiratory Therapist Registered Dietician Nurse Case Manager Speech Therapist Nursing student / Instructor Use of Ventilator Bundle Audit Tool addressing the bundle items daily 31 12/13/2015

32. The best method to prevent healthcare acquired infections including VAP is to practice good Hand Hygiene including use of Antimicrobial soap and water Alcohol Based Hand Rub (Isagel) when there is no visible soiling on hands 32 HAND HYGIENE 12/13/2015

33. Compliance with Isolation Precautions Stringent adherence to the use of Personal Protective Equipment ( PPE ) such as Gowns, Masks, Gloves will decrease the transmission of pathogenic microorganisms to ventilated patients when patients are identified as requiring Contact and Droplet Precautions 33 12/13/2015

34. Enteral Feedings Early enternal feeding decrease bacterial colonization and rate of VAP Bolus feeding should be avoided to minimize the risk of aspiration Elevate HOB 30 - 45 degrees Routinely verify tube placement No CDC recommendations for: Preferential use of small bore tubes Continuous versus intermittent feeding Post pyloric placement CDC (2003) 12/13/2015 34

35. PATIENT TURNING- Routine turning of patient for every 2 hrs increase pulmonary drainage and decrease the risk of VAP. Use of beds with continues lateral rotation can decrease the incidence of pneumonia but do not decreases mortality or duration of MV (critical care 2002;30(9):1983-1986) 12/13/2015 35

36. No Data to Support These Strategies Use of small bore versus large bore gastric tubes Continuous versus bolus feeding Gastric versus small intestine tubes. Closed versus open suctioning methods. Kinetic beds. 12/13/2015 36

37. SUMMARY Nosocomial pneumonia and especially VAP are the most frequent infectious complications in the ICU, and they significantly contribute to morbidity and mortality. VAP is an important determinant of ICU and hospital lengths of stay and healthcare costs. No standard to diagnose. Several simple preventive measures(VAP bundle) and timely initiation of appropriate antibiotics ensure better outcomes in patients with VAP. 12/13/2015 37