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    Nosocomial Pneumonia in Adults

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    Andrie Wiguna
    The document provides guidelines for diagnosing and treating hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and healthcare-associated pneumonia (HCAP), noting that prompt initiation of appropriate antibiotic therapy based on local bacterial patterns is important to prevent increased mortality, and that prevention strategies aimed at modifiable risk factors like gastric pH control and patient positioning can reduce risk. Common causative organisms include aerobic gram-negative bacilli and Staphylococcus aureus, and diagnosis involves evaluating clinical signs along with testing of respiratory samples via imaging, microscopy and culture.

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    Nosocomial Pneumonia in Adults

    Uploaded by

    Andrie Wiguna
    26 views28 pages
    The document provides guidelines for diagnosing and treating hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and healthcare-associated pneumonia (HCAP), noting that prompt initiation of appropriate antibiotic therapy based on local bacterial patterns is important to prevent increased mortality, and that prevention strategies aimed at modifiable risk factors like gastric pH control and patient positioning can reduce risk. Common causative organisms include aerobic gram-negative bacilli and Staphylococcus aureus, and diagnosis involves evaluating clinical signs along with testing of respiratory samples via imaging, microscopy and culture.

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    HAP

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    Hap

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    The document provides guidelines for diagnosing and treating hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and healthcare-associated pneumonia (HCAP), noting that prompt initiation of appropriate antibiotic therapy based on local bacterial patterns is important to prevent increased mortality, and that prevention strategies aimed at modifiable risk factors like gastric pH control and patient positioning can reduce risk. Common causative organisms include aerobic gram-negative bacilli and Staphylococcus aureus, and diagnosis involves evaluating clinical signs along with testing of respiratory samples via imaging, microscopy and culture.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    26 views28 pages

    Nosocomial Pneumonia in Adults

    Uploaded by

    Andrie Wiguna
    The document provides guidelines for diagnosing and treating hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and healthcare-associated pneumonia (HCAP), noting that prompt initiation of appropriate antibiotic therapy based on local bacterial patterns is important to prevent increased mortality, and that prevention strategies aimed at modifiable risk factors like gastric pH control and patient positioning can reduce risk. Common causative organisms include aerobic gram-negative bacilli and Staphylococcus aureus, and diagnosis involves evaluating clinical signs along with testing of respiratory samples via imaging, microscopy and culture.

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    Nosocomial pneumonia in adults

    References:
    Guidelines for the management of adults
    with hospital-acquired, ventilator-associated,
    and healthcare-associated
    鍾葛鈞 pneumonia. Am J
    Respir Crit Care Med 2005; 171:388.
    Definition of ATS/IDSA guidelines:

    1)Hospital-acquired pneumonia (HAP) is


    pneumonia that occurs 48 hours or more after
    admission, which was not incubating at the time
    of admission.
    2)Ventilator-associated pneumonia (VAP) refers to
    pneumonia that develops more than 48 to 72
    hours after endotracheal intubation.
    3)Healthcare-associated pneumonia (HCAP)
    includes any patient who was either hospitalized
    in an acute care hospital for two or more days
    within 90 days of the infection; or resided in a
    long term care facility; or received intravenous
    antimicrobial therapy, chemotherapy, or wound
    care within the 30 days prior to the current
    infection; or attends a hospital or hemodialysis
    clinic
    Principles underlie the management of
    HAP, VAP, and HCAP

    Principle (1)
    Avoid untreated or inadequately
    treated HAP, VAP, or HCAP, because
    the failure to initiate prompt
    appropriate and adequate therapy
    has been a consistent factor
    associated with increased mortality.
    Principle (2)
    Recognize the variability of
    bacteriology from one hospital to
    another, specific sites within the
    hospital, and from one time period to
    another, and use this information to
    alter the selection of an appropriate
    antibiotic treatment regimen for any
    specific clinical setting.
    Principle (3)
    Avoid the overuse of antibiotics by
    focusing on accurate diagnosis,
    tailoring therapy to the results of
    lower respiratory tract cultures, and
    shortening duration of therapy to the
    minimal effective period.
    Principle (4)
    Apply prevention strategies aimed
    at modifiable risk factors.
    ETIOLOGY
    HAP, VAP, and HCAP
    aerobic gram-negative bacilli (eg,
    Escherichia coli, Klebsiella pneumoniae,
    Enterobacter spp, Pseudomonas
    aeruginosa, Acinetobacter spp)
    gram-positive cocci (eg, Streptococcus
    spp, Staphylococcus aureus, including
    methicillin-resistant S. aureus [MRSA
    viruses or fungi is significantly less
    common except in the
    immunocompromised patient.
    Risk factors for MDR pathogens
    1.Receipt of antibiotics within the preceding 90 days
    2.Current hospitalization of 5 days
    3.Admission from a healthcare-related facility (eg,
    long-term care facility, dialysis unit)
    4.High frequency of antibiotic resistance in the
    community or in the specific hospital unit
    5.Presence of risk factors for HCAP including:
    hospitalization for two days or more in the
    preceding 90 days; residence in an extended care
    facility; home infusion therapy; chronic dialysis;
    home wound care; and a family member with an
    MDR pathogen
    6.Immunosuppressive disease and/or therapy
    Risk Factors Of VAP In Patient
    receiving Mechanical Ventilation
    Age >70 years
    Chronic lung disease
    Depressed consciousness
    Large volume aspiration
    Chest surgery
    Frequent ventilator circuit changes
    The presence of an intracranial pressure monitor or
    nasogastric tube
    H-2 blocker or antacid therapy
    Transport from the ICU for diagnostic or therapeutic
    procedures
    Previous antibiotic exposure, particularly to third generation
    cephalosporins
    Reintubation
    Hospitalization during the fall or winter season
    Mechanical ventilation for acute respiratory distress
    syndrome (ARDS)
    Prevention of HAP
    Role of gastric pH
    Decontamination of the digestive
    tract
    Patient positioning
    Subglottic drainage
    Role of gastric pH
    gastric pH by H-2 blockers or antacids
    HAP
    macroscopic gastric bleeding (P > 0.2)
    Sucralfate >ranitidine>antacid = 10% > 6% > 4%
    Early-onset pneumonia was not statistically different
    (P > 0.2).
    Late-onset pneumonia(4 days ) (P = 0.022).
    Sucralfate >antacid >ranitidine = 5% >16% > 21%
    Mortality : no statistically difference
    Role of gastric pH(2)
    Sucralfate : lower median gastric pH (P <
    0.001) and less frequent gastric
    colonization (P = 0.015)
    Molecular typing, 84% late-onset GNB
    pneumonia have gastric colonization with
    the same bacteria before pneumonia
    developed

    CONCLUSION: Stress ulcer prophylaxis


    with sucralfate reduces the risk for late-
    onset pneumonia in ventilated patients
    compared with antacid or ranitidine
    Decontamination of the digestive tract
    preventing oropharyngeal and gastric
    colonization with aerobic GNB and
    Candida spp, without disrupting the
    anaerobic flora
    locally administered nonabsorbable
    antibiotic (eg, polymyxin) and an
    aminoglycoside or fluoroquinolone +
    amphotericin B or nystatin.
    One RCS showed decrease in pneumonia
    due to GNB w/o decrease in pneumonia
    from all causes
    Decontamination of the digestive tract (2)

    A large prospective randomized trial of ICU


    in the Netherlands (p’t 934) :
    SDD group →lower mortality both in the
    ICU and during hospitalization
    (mortality :15 vs 23% ICU, 24 vs 31 %
    hospital)
    The preventative effects of SDD for HAP
    have been considerably lower in ICUs with
    high rates of endemic MDR pathogens
    selection for resistant organisms
    Patient positioning
    Several studies → supine position vs
    semirecumbent
    → predisposed to microaspiration of
    gastric contents position
    lower incidence of both clinically
    suspected and microbiologically confirmed
    HAP in semirecumbent versus supine
    patients
    No difference in mortality
    Suggest : place intubated patients in the
    semirecumbent position unless
    contraindicated.
    Subglottic drainage

    Hi-Lo EVAC tube


    (CASS)
    Subglottic drainage (2)
    Lessen risk of aspiration
    5 studies (896 intubated p’t) The use
    of CASS reduced the incidence of
    VAP by nearly half - risk ratio 0.51
    (95% CI 0.37-0.71).
    The effect of CASS in limiting VAP
    was most pronounced among
    patients expected to require >72
    hours of mechanical ventilation.
    Diagnosis of Pneumonia
    Clinical definition –
    New or progressive infiltrate
    Fever
    Leukocytosis
    Purulent tracheobronchial secretions
    unreliable compared with the gold
    standard of lung histology
    One study compared the clinical diagnosis
    of HAP with the histopathologic diagnosis
    obtained at autopsy: pneumonia was
    diagnosed correctly in only 2/3 of cases
    Noninfectious causes of fever and
    pulmonary infiltrates in VAP
    Chemical aspiration without infection (Aspiration
    pneumonitis)
    Atelectasis
    Pulmonary embolism
    Acute respiratory distress syndrome (ARDS)
    Pulmonary hemorrhage
    Lung contusion
    Infiltrative tumor
    Radiation pneumonitis
    Drug reaction
    Bronchiolitis obliterans organizing pneumonia
    (BOOP)
    Diagnosis
    Imaging
    Gram's stain and culture
    Bronchoscopy
    Imaging
    limited value in ventilated patients.
    In one study, only 1/3 of ventilated
    patients with a new or worsening alveolar
    infiltrate had pneumonia at autopsy
    No single radiologic sign was clearly
    correlated with the diagnosis.
    The most reliable sign was the finding of
    air bronchograms, but predicted
    pneumonia in only 64 percent of cases.
    ARDS and alveolar hemorrhage were the
    most common disorders mistaken for
    pneumonia.
    Gram's stain and culture
    unreliable due to contamination with bacteria
    colonizing the oropharynx
    The presence of many polymorphonuclear
    leukocytes (and few epithelial cells) and bacteria,
    which are morphologically consistent with
    bacteria found on culture, improve the predictive
    power
    In addition, the lack of isolation of a pathogen (eg,
    MRSA or Pseudomonas) from a well-collected and
    adequate expectorated sputum sample can be
    used to narrow the antimicrobial regimen
    Blood cultures are extremely helpful when
    positive, but the yield is low
    Bronchoscopy
    Protected brush specimen (PBS)
    Using a threshold of >10(3) colony forming units
    (CFU)/mL
    sensitivity : 64 to 100 %
    specificity : 60 to 100 %
    Bronchoalveolar lavage (BAL)
    Samples approximately one million alveoli,
    recovers 5x -10x the number of organisms
    obtained by PBS. Quantitative cultures using a
    threshold of >10(4) CFU/mL
    sensitivity : 72 - 100 %
    specificity : 69 - 100 %
    1) Baseline
    2) When VAP is
    clinically
    suspected
    3) 3 days later
    Patients with no known risk factors
    for MDR pathogens
    ceftazidime (2 g every eight hours)

    sulbactam (3 g Q6H) or tazobactam (4.5 g


    Q6H) (eg, Enterobacter spp, Serratia spp,
    Pseudomonas spp)

    Levofloxacin 750 mg daily or ciprofloxacin


    400 mg every eight hours

    Meropenem 1 g every eight hours


    Patients with known RF for MDR pathogens
    3 combination
    Antipseudomonal cephalosporin eg, ceftazidime (2 g Q8H) or
    cefepime (2 g Q8H) OR
    Antipseudomonal carbapenem eg imipenem (500 mg Q6H) or
    meropenem (1 g Q8H) OR
    Piperacilin-tazobactam (4.5 g Q6H)
    +
    Antipseudomonal FQ, preferred regimen if Legionella is likely,
    eg, levofloxacin (750 mg QD) ciprofloxacin (400 mg Q8H)
    OR
    Aminoglycoside eg,gentamicin or tobramycin (7 mg/kg QD
    adjusted to a trough level <1 µg/mL) or amikacin (20 mg/kg
    QD adjusted to a trough level <4-5 µg/mL)
    +
    (if MRSA is suspected, there are MRSA risk factors, or high
    incidence of MRSA locally):
    Linezolid (600 mg Q12H) OR Vancomycin (15 mg/kg Q12H,
    dosed so that trough levels are 15 to 20 µg/mL)
    To:Ventilator-Associated
    Pneumonia

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