Nosocomial Nosocomial Burden of Hospital-Acquired Pneumonia Burden - - PDF document

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Nosocomial Nosocomial Burden of Hospital-Acquired Pneumonia Burden - - PDF document

Mar 25, 2023 287 likes •407 views

Nosocomial Nosocomial Burden of Hospital-Acquired Pneumonia Burden of Hospital-Acquired Pneumonia Pneumonia Pneumonia Second most common nosocomial infection in the U.S. 5-10 episodes per 1000 admissions 25% of all intensive care

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Nosocomial Pneumonia Nosocomial Pneumonia

Meredith Deutscher, MD Troy Schaffernocker, MD Ohio State University

Definition of Nosocomial Pneumonia Definition of Nosocomial Pneumonia

  • Pneumonia that develops in a patient

hospitalized ≥48 hours

  • Also known as hospital-acquired pneumonia

(HAP)

  • Ventilator-associated pneumonia (VAP)

Pneumonia that develops ≥48 hours after endotracheal intubation

Burden of Hospital-Acquired Pneumonia Burden of Hospital-Acquired Pneumonia

  • Second most common nosocomial infection in

the U.S. 5-10 episodes per 1000 admissions 25% of all intensive care unit infections

  • Attributable mortality rate: 33-55%
  • Increases hospital length of stay 7-9 days
  • Increases hospital cost by $40,000

<5 Days: Non-Multidrug-Resistant Bacteria <5 Days: Non-Multidrug-Resistant Bacteria

  • Streptococcus pneumoniae
  • Moraxella catarrhalis

Haemophilus influenzae

  • Haemophilus influenzae
  • Anaerobes
  • Legionella pneumophila
  • Gram-negative rods, not extended-spectrum ß-

lactamase (ESBL) producers

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≥5 Days: Multidrug-Resistant Bacteria ≥5 Days: Multidrug-Resistant Bacteria

  • Methicillin-resistant Staphylococcus aureus
  • Pseudomonas aeruginosa

Pseudomonas aeruginosa

  • Acinetobacter species
  • Gram-negative rods, ESBL producers
  • Gram-negative rods, carbapenemase producers

Hospital-Acquired Pneumonia with Viral and Fungal Pathogens Uncommon Hospital-Acquired Pneumonia with Viral and Fungal Pathogens Uncommon

Viral pathogens

  • Influenza
  • Parainfluenza

R i t ti l Fungal pathogens

  • Candida spp.
  • Aspergillus

fumigatus

  • Respiratory syncytial

virus

  • Adenovirus
  • Novel influenza A

(H1N1) virus was the dominant circulating influenza virus in 2009 fumigatus

Diagnosis Diagnosis

ATS/IDSA

HAP HAP

  • New radiographic infiltrate after 48 hours of

hospitalization.

  • Clinical findings suggestive of infection

(including new fever, leukocytosis, purulent sputum, and decline in oxygenation).

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HAP HAP

  • Requires entry of microbial pathogens into

the lower respiratory tract.

Defense Defense

  • Upper Airway

Sneezing Sneezing Swallowing Expectoration

Defense Defense

  • 80% of cells in central airways Ciliated,

pseudostratified, columnar epithelium.

Defense Defense

  • Alveoli

Alveolar Macrophages (phagocytes) (phagocytes) Lining fluid: surfactant, fibronectin, immunoglobulins which can opsonize or lyse microbial pathogens.

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Pathophysiology Pathophysiology

  • Inflammatory Exudate

Pulmonary Consolidation Systemic Manifestations

  • Fever
  • Chills
  • Myalgias
  • Malaise

Transmission Transmission

  • Aspiration

Level of consciousness (alcohol, drugs) Neurologic Dysfunction (seizure, stroke) Mechanical Impairments (endotracheal tube, p ( nasogastric tube)

  • Inhalation

Particles > 10μm get deposited in nose and

  • ropharynx

5-10μm Central airways <5μm can make it all the way to alveoli

Transmission Transmission

  • Hematogenous

Extrapulmonary Sites

  • Endocarditis

V l C th t i f ti

  • Vascular Catheter infections
  • Retropharyngeal infections
  • Direct Inoculation/Contiguous Spread

Tracheal intubation Penetration of the chest wall

HAP HAP

  • Requires entry of microbial pathogens into the

lower respiratory tract.

Aspiration of oropharyngeal pathogens Aspiration of oropharyngeal pathogens Leakage of bacteria around an endotracheal tube Less common: Direct inhalation, Hematogenous spread, Translocation from the GI tract.

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Physical Exam Physical Exam

  • Fever
  • Purulent Sputum
  • Signs of pulmonary consolidation

D ll Dullness Increased fremitis Egophony Bronchial breath sounds Rales

  • Confirm the presence and

location of an infiltrate

  • Assess the extent of

Diagnosis: Chest Radiography Diagnosis: Chest Radiography

infection

  • Detect pleural involvement
  • Gauge hilar

lymphadenopathy

  • Monitor response to

therapy

  • Sputum

Gram’s staining Culture

  • Fiberoptic Bronchoscopy

Diagnosis: Sample Analysis Diagnosis: Sample Analysis

p py

Bronchoalveolar lavage (BAL) Protected Sheath Brush Transbronchial Biopsy

  • Thoracentesis

Consider if significant pleural effusion

  • Open-Lung Biopsy

HAP HAP

  • Invasive Diagnostic Strategy vs Clinical

Diagnosis?

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Algorithm Algorithm

ATS/IDSA

HAP HAP

  • Invasive Diagnostic strategy vs Clinical

Diagnosis?

Lower respiratory culture should be obtained

  • Bronchoscopically
  • Non-bronchoscopically
  • Bronchoscopic strategy may improve outcomes –
  • ne study showed improved 14 day mortality

Endotracheal Aspirate Endotracheal Aspirate

  • Blind tracheobronchial aspiration

Insertion of a flexible catheter into the distal trachea distal trachea

  • Bronchoscopically guided

BAL (Bronchoalveolar Lavage) Protected Specimen Brush

Selecting Antimicrobial Regimens Selecting Antimicrobial Regimens

  • Choosing an empiric regimen

g g

  • Choosing a specific regimen
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Selecting an Empiric Regimen Selecting an Empiric Regimen

1. Collect blood and sputum cultures before administering antimicrobials administering antimicrobials 2. Determine whether patient is at risk for infection with MDR pathogen

Risk Factors for Infection with MDR Pathogens Risk Factors for Infection with MDR Pathogens

  • Receiving antimicrobial therapy in past 90 days
  • Current hospital stay ≥5 days
  • Exposure to hospital’s ICU MDR pathogens
  • Immunocompromised status

Immunocompromised status

  • Risk factors for healthcare-associated

pneumonia: Resident of long term-care facility Hospitalized for ≥2 days in past 90 days Received hemodialysis in past 30 days Receiving wound care Family member with MDR pathogen

Selecting an Empiric Regimen, cont’d. Selecting an Empiric Regimen, cont’d.

3. Consult hospital antibiogram

  • ICU may have separate antibiogram
  • Indicates which antimicrobials are more likely

to be effective against a particular pathogen

Selecting an Empiric Regimen, cont’d. Selecting an Empiric Regimen, cont’d.

4. Consider what antimicrobials the patient has already received

  • What did the patient receive in the past 14

days? y

  • Did the patient develop HAP while on

treatment? If possible, the empiric regimen should be comprised of agents from antimicrobial classes to which the patient has not been recently exposed.

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8 Keys to Empiric Regimen Selection Keys to Empiric Regimen Selection

  • Empiric therapy should be broad enough to cover

all suspected pathogens all suspected pathogens.

  • Optimal dosing is needed to control infection.

Empiric Regimens: Not at Risk for MDR Infection Empiric Regimens: Not at Risk for MDR Infection

  • 1. Ceftriaxone
  • 2. Fluoroquinolone
  • 3. Ampicillin/sulbactam
  • 4. Ertapenem

+/- Azithromycin

Empiric Regimens: At Risk for MDR Infection Empiric Regimens: At Risk for MDR Infection

A. B. C.

MRSA coverage antipseudomonal cephalosporin aminoglycoside antipseudomonal carbepenem antipseudomonal fluoroquinolone ß-lactamase inhibitor

Am J Respir Crit Care Med 2005;171:388-416.

Specific Infection Specific Regimen Specific Infection Specific Regimen

  • Reassess empiric regimen after 48 hours
  • Goal: de-escalate or streamline antimicrobial

coverage

  • Base on microbiologic data and clinical response
  • Base on microbiologic data and clinical response
  • Improves patient outcome by minimizing

complications caused by broad-spectrum coverage

  • C. difficile infection

Selection of MDR pathogens

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Limit Duration Limit Duration

7 days

  • Uncomplicated HAP
  • r VAP, and
  • Responding to

14 days

  • P. aeruginosa
  • Acinetobacter species

N t di t

  • Responding to

therapy

  • Not responding to

therapy Prolonged therapy leads to colonization with resistant organisms.

Assess Nonresponders Assess Nonresponders

  • Wrong diagnosis (not pneumonia)
  • Wrong antimicrobial

Wrong organism or drug-resistant organism S b ti l d i Suboptimal dosing

  • Complication
  • C. difficile

Empyema or abscess Drug fever

Prevention Measures: Aspiration Precautions Prevention Measures: Aspiration Precautions

  • Monitor sedation
  • Elevate head of bed
  • Consider speech and swallow consult

Prevention Measures: Vaccination Prevention Measures: Vaccination

  • Assess vaccination status prior to discharge

Pneumococcal vaccine Influenza vaccine Influenza vaccine

  • These vaccines may be given together
  • S. pneumoniae is a leading cause of vaccine-

preventable illness and death in the U.S. Approximately 70 million people with existing indications for vaccination are not vaccinated

NHIS, 2007

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Prevention Measures: Infection Control Prevention Measures: Infection Control

  • Hand hygiene to reduce spread of multidrug-

resistant pathogens

  • Transmission based precautions
  • Transmission-based precautions

Contact Droplet Airborne

Prevention of VAP Prevention of VAP

  • Intubation and Mechanical Ventilation

increase the risk of pneumonia 6 to 21 fold in prospective studies. p p

VAP – ET tube VAP – ET tube

  • Endotracheal tube

Cuff pressure 20 cm H2O Aspiration of subglottic secretions may help prevent early VAP p p y

VAP – GI considerations VAP – GI considerations

  • Oral antiseptics – positive results in

cardiothoracic surgery patients

  • Selective Decontamination of the Digestive tract –

Mixed results Mixed results

  • Antacids, H2 blockers, Proton Pump inhibitors –

Mixed results, increased enteric gram negative colonization

  • Probiotics - jury still out
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  • Early enteral feeding may increase

incidence

VAP – GI considerations VAP – GI considerations

  • Post pyloric feeding may reduce incidence

based on a metaanalysis

VAP – Vent Considerations VAP – Vent Considerations

  • Frequent circuit changes do not help
  • Humidifiers and heat-moisture exchangers

do not impact incidence

  • Use of Orotracheal tubes and orogastric

tubes, rather than nasotracheal and nasogastric can reduce Nosocomial sinusitis (potential bacterial reservoir)

  • Minimize duration of mechanical ventilation

Sedation protocols Weaning protocols

R i t b t i i k

VAP – Vent Considerations VAP – Vent Considerations

  • Re-intubaton increases risk
  • Ventilator Bundles
  • Educational materials, guidelines,

checklists, protocols

VAP - Considerations VAP - Considerations

  • Semi-recumbent position is better than

supine – Head of Bed >30-45 degrees E l t h t iti d t

  • Early tracheostomy – some positive data,

but yet to be applied to a broad ICU population