1. Nosocomial Pneumonia Hospital Acquired, Ventilator Associated, Healthcare Associated Pneumonia

2. Outline and Goals Learn Definitions of types of NP Learn Pathogenesis/Epidemiology Learn Diagnosis Learn Initial Management Learn Impact of NP Learn Prevention of NP

3. Hospital Acquired Pneumonia “occurs 48 hours or more after admission” “was not incubating at the time of admission” Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia American Thoracic Society and the Infectious Diseases Society of America Am J Respir Crit Care Med Vol 171. pp 388–416, 2005

4. Ventilator Associated Pneumonia > 48 to 72 hours on closed ventilator Non-Invasive Ventilation not a factor

5. Healthcare-Associated Pneumonia Nursing Home/LTCH resident >48Hr hospital stay in past 90 days Within past 30 days had: Wound Care or I.V. Therapy HD or Hospital Clinic visit

6. Pathogenesis Colonization of Lower Respiratory Tract (LRT) Vulnerable Host Defenses

8. Colonization LRT Microaspiration Introduction by devices (catheters, aerosolized material) Direct Leakage around ETT cuff Biofilm

9. Vulnerable Host Defenses Cellular/Humoral Defenses ‣ Immunosupressed, infected, surgery, organ failure, recent antibiotics, frequent transfusions of blood/blood products Mechanical Defenses ‣ Turbinates, vocal chords, ciliated epithelium, cough, acidified stomach

10. VAP Incidence 90% of the HAP in the ICU is VAP Incidence increases over time but risk highest early in vent course 3%/day from day 0 to 5, 2%/day from day 5-10, 1%/day after So risk starts at minute zero of intubation

11. Microbiology Frequently polymicrobial Multidrug Resistance (MDR) Problem Similar spectrum in all types NP Viral/Fungus very uncommon

12. Aerobic Gram Negatives Pseudomonas Klebsiella Acinetobacter Very Institution Specific Stenotrophomonas Legionella

13. Gram Positives Most commonly staph ICU in USA MRSA>MSSA Pneumococcus much less common

14. Risk for MDR HCAP risks >5 days since admission Antibiotics in past 90 days Immunosupressed High MDR rate in hosp/unit

15. Suspect Pneumonia if: New/Progressive CXR findings Clinical Infection Findings Fever, Leukocytosis, Leukopenia Respiratory Findings Purulent Sputum, Deoxygenation

16. Additional Clinical Clues Mental Status Change in Elderly New Crackles, Egophony Worsening Dyspnea or Cough Increased Need for Vent Support Increased Suction Requirements

17. Diagnosis: Cultures Sensitivity and specificity poor with clinical criteria alone especially with vented patients CXR+ and 2/3 clinical findings present sensitivity 69% specificity 75% Fabregas et al, Thorax 1999;54:867–873

18. Lower Respiratory Cx Bronchoscopy or ETT Aspiration Both good NPV (>90%) ETT aspirate can’t distinguish colonizers; may lead unnecessary abx Bronch invasive; not as accessible

19. Blood Cultures Always obtain Limited sensitivity (25%)* May be extrapulmonary so limited specificity* For non-vented patients may be only accessible culture *Luna CM et al, Chest 1999;116:1075

20. Microbiological Diagnosis Culture if clinically suspect NP, BEFORE antibiotics if possible Always try LRT Cx or Sputum Always blood culture Avoid unnecessary sampling to prevent unneeded abx and MDR

21. Initial Management Empiric early therapy with APPROPRIATE antibiotics Do not delay therapy for microbiological sampling Delay in therapy has higher mortality

22. Appropriate Antibiotics? HAP with no MDR risks? Becoming less common, but can use Ceftriaxone Ampicillin/sulbactam Moxifloxacin

23. Appropriate Antibiotics Otherwise should start with Antipseudomonal therapy Cefepime, Imipenem, Meropenem plus MRSA Therapy Vancomycin, Linezolid

24. Impact of HAP/VAP 25% ICU infections HAP Most common cause for antibiotic use in ICU - likely contributor to MDR HAP extends LOS by 7-10 days Mortality ranges 30 - 70% Cost of one case $40,000

25. Prevention We give patients this. The chief complaint on entering the health care system is never: “I have ventilator associated pneumonia” Everyone who touches the patient has a responsibility to prevent it.

26. Hand Washing Before and after every patient contact however small Dirty hands are lethal weapons Soap/Water 30 seconds (“Happy Birthday” or “ABC” twice) Alcohol Scrub acceptable

27. Circuit Integrity The ventilator tubing (called “circuitry”) is changed weekly More frequent changes do not reduce VAP Avoid opening it unnecessarily - use in- line suction catheter if possible

28. Patient Positioning Elevate Head of Bed (HOB) to 30-45˚ Reduces clinical rate from 34% to 8%* Reduces culture rate from 23% to 5% * Every vented patient should have HOB >30˚at all times from the start unless absolute contraindication Lancet 1999 Nov 27;354:1851

29. Judicious Intubation Cannot get VAP if not on the Vent NIPPV good for CHF, COPD Not good for AMS, Secretions Do not delay necessary intubations

30. Removal of Ventilator Cannot get VAP if not on the Vent Patients need aggressive weaning Includes daily waking from sedation Includes daily wean trials if meets criteria (see weaning protocol)

31. IHI Bundle 1. HOB Elevation 2. Daily Sedation Vacation 3. Daily Wean Trials 4. DVT Prophylaxis 5. GI Ulcer Prophylaxis

32. Some institutions self-report VAP rates of 0% after adopting IHI bundle Only 3/5 recommendations directly impact VAP

33. HAP/VAP/HCAP significant cause of hospital/ICU Morbidity Significant cost in resources, patient safety and likely mortality Significant public health problem; possibly fueling development of MDR Summary

34. Once suspect diagnosis must attempt to confirm with cultures Empiric antibiotics must be started quickly Coverage for MRSA and Pseudomonas in most cases is warranted

35. Summary Rapid de-escalation of antibiotics Narrow if pathogen known Remove if improves and cultures negative

36. Summary Prevention Essential Handwashing and Infection Control HOB elevation Avoid unnecessary intubation Wake and Wean Aggressively Maintain Circuitry Integrity