Karen Hoover MSIPC Fundamentals, 2014

 Proportion of all HAIs: ◦15-22 % of all HAIs in acute care ◦ almost 25% of all nosocomial infections in ICU ◦13-48% in LTCF ◦Ambulatory Care – approximately 1.4% (>1.5 million)/ million ED visits were for pneumonia  Risk Factors: ◦Mechanical ventilation (6-21x higher than those without ventilation) – acute care. 300,000 pts/yr on ventilator in US ◦Aspiration, Dysphasia, poor oral - LTC ◦Being an older adult (10x more likely) ◦Other lung disease, such as COPD

Major Site of InfectionEstimated No. Pneumonia157,500 Gastrointestinal Illness123,100 Urinary Tract Infections93,300 Primary Bloodstream Infections71,900 Surgical site infections from any inpatient surgery 157,500 Other types of infections118,500 Estimated total number of infections in hospitals 721,800

 hospitalization in an acute care hospital for two or more days in the last 90 days;  residence in a nursing home or long-term care facility in the last 30 days  receiving outpatient intravenous therapy (like antibiotics or chemotherapy) within the past 30 days  receiving home wound care within the past 30 days  attending a hospital clinic or dialysis center in the last 30 days  having a family member with known multi-drug resistant pathogens (MRDO)

 New or progressive infiltrate on the chest X-Ray with one of the following:  Fever > 37.8 °C (100 °F)  Cough with Purulent sputum or “change in sputum”  Shortness of breath  Leukocytosis> cells/μl  May have Tachypnea  Lab test changes  Mental changes or confusion  Decreased blood pressure

 Have had chest surgery or other major surgery  Have another serious condition, especially another lung disease, such as chronic obstructive pulmonary disease (COPD).chronic obstructive pulmonary disease (COPD)  Are not eating enough healthy foods and are malnourished.  Have a weak immune system.immune system  Have been in the hospital for a long time.  Are taking many antibiotics.  Are alcoholic  Aspirate saliva or food into lungs

 Bacterial pneumonia: The majority of cases related to various gram negative bacilli (52%) and S. aureus (19%), usually of the MRSA type. Others are Haemophilus spp. (5%). In the ICU results were S. aureus(17.4%), P. aeruginosa(17.4%), Klebsiella pneumoniae and Enterobacter spp. (18.1%), and Haemophilus influenzae(4.9%).  Viral pneumonia: influenza and respiratory syncytial virus (RSV) and, in the immunocompromised host, cytomegalovirus (CMV)- cause 10-20% of infections.  Mycoplasma Pneumonia: not viruses or bacteria, but they have traits common to both.  Other: affect immune-compromised individuals. PCP pneumocystis carinii pneumonia.

 Legionnaires disease (L. pneumophila)  Pertussis (Bordetella pertussis)  Aspergillosis (Aspergilllus spp.  Viral infections: ◦ Common cold viruses ◦ Influenza ◦ Respiratory syncytial virus

 Pharyngitis: ◦ inflammation of the pharynx. It frequently results in a sore throat. Pharyngitis may be caused by a variety of microorganisms.sore throat ◦ Group A Streptococcus or S. pyogenes – “strep throat”  Sinusitis: inflammation or infection of the sinuses

 Bronchitis: inflammation of the main air passages (bronchi). ◦ Symptoms - cough, shortness of breath and chest tightness. ◦ Two main types: acute and chronic.  Acute: caused by cold viruses  Chronic: type of COPD; long-term condition

Endotracheal tube bypasses upper respiratory tract defenses, allows for pooling of oropharyngeal secretions, prevents effective cough.

 Bacteria enter lower respiratory tract via aspiration from: ◦ Oropharynx (majority) ◦ Hematogenous spread (?GI tract – maybe but unproven)  Factoid: 45% of non-hospitalized adults aspirate during sleep  Home CPAP machines  Risks in Healthcare settings: ◦ Abnormal swallowing ◦ Depressed level of consciousness ◦ Mechanical Ventilation ◦ Thoracic and abd. surgery wr/preview/mmwrhtml/ rr5303a1.htm

 Acute care - ◦ Prolonged length of stay (3-6d) ◦ Excess cost/case = up to $40k ◦ Associated mortality = 20-33%  LTC – ◦ 1 st or 2 nd most common site of infection ◦ Seasonal variation, more frequent during influenza season ◦ Associated mortality = 6-23%

1. CDC. 2. Bartlett JG et al. Clin Infect D. Am J Respir Crit Care Med 2005 Various Types of Pneumonia

 Acute Care: ◦ Gram negatives:  Acinetobacter  Pseudomonas, etc. ◦ Gram Positives, less so but:  S. aureus ◦ Early onset can incl.-  S. pneumoniae  H. influenzae  E. coli, Klebsiella  LTC: ◦ 79% of cases – no pathogen isolated ◦ S. pneumoniae 0-39%, ◦ S. aureus 0-33%, ◦ H. influenzae in 0-19% ◦ aerobic Gram-negative bacilli in 0-55%

 Patient on mechanical ventilation > 2 days  Baseline period of stability or improvement, followed by sustained period of worsening oxygenation.  Ventilator-Associated Condition (VAC)  General, objective evidence of infection/inflammation  Infection-Related Ventilator-Associated Complication (IVAC)  Positive results of laboratory/microbiological testing  Possible or Probable VAP

 VAEs are identified by using a combination of objective criteria: deterioration in respiratory status after a period of stability or improvement on the ventilator, evidence of infection or inflammation, and laboratory evidence of respiratory infection. The following pages outline the criteria that must be used for meeting the VAE surveillance definitions

 Patient has a baseline period of stability or improvement on the ventilator, defined by ≥ 2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values. The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2.

 Patient meets criteria for VAC  AND …  On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, the patient meets both of the following criteria:  1) Temperature > 38 °C or < 36°C, OR white blood cell count ≥ 12,000 cells/mm3 or ≤ 4,000 cells/mm3.  AND  2) A new antimicrobial agent(s) is started, and is continued for ≥ 4 calendar days. 

 Develops 48 hours or longer after mechanical ventilation  There is no minimum period of time that the ventilator must be in place in order for the PNEU to be considered ventilator-associated.  Ventilator-Associated Pneumonia (VAP) Rate per 1,000 Ventilator Days  Track the measure monthly nhsn.cdc.gov/nhsndemo/help/Patient_Safety_Compon ent/Site_Definitions/Clinically_Defined_Pneumonia_PN U1.htm

VENTILATOR ASSOCIATED EVENT Q JANUARYFEBRUARYMARCH VACIVACPoss VAPProb VAPVACIVACPoss VAPProb VAPVACIVACPoss VAPProb VAP 6 ICU SICU NICU TICU CCU TOTAL VAE's 8 64 Summary VAC10 IVAC7 Poss VAP1 Prob VAP0 Total VAE's18

 Physician’s diagnosis of pneumonia alone is not an acceptable criterion for nosocomial pneumonia.  Pneumonia due to gross aspiration (for example, in the setting if intubation in the emergency room or operating room) is considered nosocomial if it meets any specific criteria and was not clearly present or incubating at the time of admission to the hospital  Multiple episodes of nosocomial pneumonia may occur in critically ill patients with lengthy hospital stays. When determining whether to report multiple episodes of nosocomial pneumonia in a single patient, look for evidence of resolution of the initial infection. The addition of or change in pathogen alone is not indicative of a new episode of pneumonia. The combination of new signs and symptoms and radiographic evidence or other diagnostic testing is required.

 Hand Hygiene  Pneumonia Vaccine According to the CDC, adults are nearly as likely to get pneumococcal disease as people 65 and older. Enhancing host defense: flu immunization  Sterilization or Disinfection and Maintenance of Equipment and Devices: ventilator, breathing circuits, etc.  Standard Precautions : mask with open artificial airway suctioning  Prevent Aspiration – elevate head of the bed  Prevent post-op pneumonia: early mobility  Good oral hygiene

 Pneumococcal,  Haemophilus influenzae type b (Hib),  Pertussis (whooping cough),  Varicella (chickenpox),  Measles, and  Influenza (flu) vaccine.

 Subglottic suctioning performed ◦No remaining secretions above ET tube cuff ◦Store Yankauer in container with airflow – Do not place on bed  Oral cavity cleansed with suction swab  Mucosa moisturized with swab ◦To assess dryness use gloved finger and touch buccal mucosa ◦Offer moisturizer a la cart if not using a company package

Tooth brushing  Subglottic suctioning performed  Ensure proper ETT cuff inflation  > two minutes  Do not have to use toothpaste  Use soft toothbrush making small circular movements  Remove all visible plaque and soft debris  Clean tongue, gums and palate  Clean toothbrush with water removing visible debris  Store toothbrush upright in container with airflow (available for purchase or not)

 ID S A G U I D E L I N E S published August 30, 2011  When Does a Child or Infant With CAP Require Hospitalization?  When Should a Child With CAP Be Admitted to an Intensive Care Unit (ICU) or a Unit With Continuous Cardiorespiratory Monitoring?  What Diagnostic Laboratory and Imaging Tests Should Be Used in a Child With Suspected CAP in an Outpatient or Inpatient Setting?  What Additional Diagnostic Tests Should Be Used in a Child With Severe or Life-Threatening CAP?   318ab

All pt’s should have CXR Blood culture CBC ESR/CRP Urinary antigen for Pneumococcal infection is not recommended Sputum samples if able (weak; low evidence) Rapid tests for Influenza and viruses should be used Mycoplasma pneumoniae should be tested for if suspicious No reliable test for Chlamydophila pneumoniae

 For the fully immunized child in regions that do not demonstrate high-level pneumococcal penicillin resistance: ◦ Ampicillin or Penicillin G are first-line ◦ Azithromycin for suspected atypical pneumonia (with a beta-lactam if diagnosis is in question) ◦ Vancomycin or clindamycin should be added when S. aureus is suspected by labs, clinical findings or imaging ◦ Ceftriaxone or cefotaxime are alternatives