1. Depart. Of Pulmonology and Critical Care Medicine R4 백승숙

2. Introduction Diagnosis of Nosocomial pneumonia - Clinical and Radiographic Diagnosis - Microbiological/Etiological Diagnosis - Biomarkers - Recommendations for Diagnostic Approach Prevention of Nosocomial pneumonia - Pharmacologic Approaches - Nonpharmacologic Approaches Treatment Protocols for VAP Prevention Protocols for VAP Conclusion

3. Introduction Nosocomial pneumonia (NP) ‘Difficult diagnosis’ Underlying cardiopulmonary disorders (Critically ill patient) Nonspecific radiographic and clinical signs ‘Problematic’ Greater risk of hospital mortality Longer lengths of stay on mechanical ventilation and in the ICU Greater need for tracheostomy Significantly increased medical care costs  Brief overview of current approaches for the diagnosis of NP and focus on strategies for prevention

5. Diagnosis of NP - Clinical and Radiographic Diagnosis Clinical criteria are nonspecific for the diagnosis of NP Fever, Leukocytosis, and Purulent secretions  Complicate other noninfectious pulmonary conditions such as atelectasis and the acute respiratory distress syndrom Chest radiograph can be nonspecific for the diagnosis of NP No roentgenographic sign correlated well with the presence of pneumonia in mechanically ventilated patients - Wunderink et al. The most frequently employed clinical diagnosis of VAP The presence of a new or progressive consolidation on chest radiology At least two of the following clinical criteria : fever 38°C, leukocytosis or leukopenia, and purulent secretions

8. Several studies have evaluated the value of quantitative bacteriologic data in establishing the diagnosis of VAP compared to pathologic and clinical criteria Quantitative cultures of respiratory specimens obtained by BAL Lung histology of guided or blind specimens - Torres et al. No one absolute gold standard for the diagnosis of VAP The clinical relevance of appropriate antibiotic treatment for VAP supports a definition employing lower respiratory tract microbiology as opposed to clinical criteria alone Diagnosis of NP - Microbiological/Etiological Diagnosis

9. Procalcitonin(PCT) monitoring ; Helpful in differentiating bacterial infections from other inflammatory conditions or non-bacterial infectious diseases - Limit the overuse of antibiotics - Early evaluation of disease severity for patients with pneumonia Randomized trial - Briel et al. PCT-guided approach to antibiotic therapy vs. Standard approach (PCT level, ≤0.1 or ≤0.25 μ g/L)  Antibiotics discouraged (PCT level, >0.25 μ g/L)  Antibiotics encouraged  With PCT-guided therapy, the antibiotic prescription rate was 72% lower (95% confidence interval, 66% to 78%) than with standard therapy Diagnosis of NP - Biomarkers

10. As none of the currently available diagnostic tests provides an absolute accurate diagnosis of VAP when used alone, a strategy that combines diagnostic modalities is advocated Patients with suspected VAP  ‘Evaluation’ ; Supported by local expertise and should include imaging procedures (chest radiograph, computed tomography), bacteriologic cultures from the lower respiratory tract, and possibly biomarkers  Determine the likelihood that VAP is present Guide therapy in a manner that attempts to optimize patient outcomes Diagnosis of NP - Recommendations for Diagnostic Approach

11. Delays in the initiation of appropriate antibiotic therapy should be avoided as they are associated with increased mortality The results of lower respiratory tract cultures are principally used to facilitate modification of the initial antimicrobial regimen

12. Prevention of NP - Pharmacologic Approaches

13. Prevention of NP - Nonpharmacologic Approaches

14. Treatment Protocols for VAP The antimicrobial management of VAP = A balancing act Providing appropriate initial treatment in a timely manner based on the knowledge of local pathogens and their antimicrobial susceptibility vs. Minimizing further development of antimicrobial resistance = Antimicrobial avoidance = Broad-spectrum narrow-spectrum antibiotic therapy

15. Treatment Protocols for VAP Failure to provide treatment with an appropriate initial antimicrobial regimen Delays of 24 hrs after meeting diagnostic criteria for VAP  Does not result in outcomes equal to those achieved in patients treated with an initial appropriate antimicrobial regimen American Thoracic Society/Infectious Diseases Society of America guidelines Combination of antimicrobials targeting the most common bacterial pathogens associated with early- and late-onset infection Ibrahim et al. Lancaster et al. Appropriate Initial Therapy and De-Escalation

18. Treatment Protocols for VAP Antimicrobial de-escalation should occur when possible, based on the patient’s clinical response to the empirical antimicrobial treatment and microbiological testing results Decreasing the number and spectrum of antibiotics Shortening the duration of therapy when appropriate Rello and colleagues. Micek and colleagues. Stop one or more antibiotics if a noninfectious etiology for pulmonary infiltrates was identified or if all of the following criteria were met 1) Temperature of < 38.3°C 2) White blood cell count <10 x10 3 or decreased 25% from peak value 3) Improvement or lack of progression of the chest radiograph 4) Absence of purulent sputum 5) PaO 2 /FIO 2 ratio of >250 Appropriate Initial Therapy and De-Escalation

19. Protocols have also been employed successfully for the prevention of VAP An education based program at Barnes-Jewish Hospital Respiratory care practitioners and ICU nurses A multidisciplinary task force to highlight correct practices for the prevention of VAP - Zack JE et al. A protocol for the prevention of VAP in trauma patients Head of bed elevation Oral cleansing with chlorhexidine, Once-daily respiratory therapist driven weaning attempt Conversion of nasogastric to orogastric feeding tube - Lansford et al. Prevention Protocols for VAP

21. Conclusion Clinicians need to develop systems within the ICUs aimed at optimizing the care of patients in order to improve their clinical outcomes Protocols, standardized order sets, check-lists, computerized clinical decision support(CCDS) systems, and clinical practice teams all provide approaches to the enhancement of critical care