Optimizing Outcomes in Patients with Health Care/Ventilator Associated

Pneumonia

Jessica Clark, Pharm.D

Objectives

• Discuss the impact of the timing of initiation of antimicrobials in patients with nosocomial pneumonia

• Discuss the impact of appropriate initial selection of antimicrobials for treatment of nosocomial pneumonia

Nosocomial Pneumonia

Health Care Associated (HCAP)

Hospital Acquired (HAP)

Ventilator Associated (VAP)

• Hospitalized for ≥ 2 d during past 90 days• Nursing Home or Long Term Care facility• Recent IV antibiotics, chemotherapy, or wound care in past 30 days• Dialysis

• > 48 hr after hospitalization

• > 48 – 72 hr after ET intubation

Am J Respir Crit Care Med 2006;171:388-416

Identifying Pneumonia

√ Fever√ Leukocytosis√ Purulent tracheal secretions√ New or persistent infiltrates√ Oxygenation

Impact of Delays in Initiation of Antimicrobial Therapy for Septic Shock

• Retrospective review conducted in 14 ICUs and 10 hospitals in the U.S and Canada

• 2,371 adult patients with septic shock• 80% survival in patients receiving appropriate antimicrobial

within first hour of documented hypotension– Each hour of delay decreased survival by 8%– Mortality already significantly higher by second hour compared to

appropriate therapy within first hour (OR 1.67; 95% CI 1.12-2.48)• Time to initiation of appropriate antimicrobial therapy was

single strongest predictor of survival– Median time = 6 hours

Kumar A et al. Crit Care Med 2006;34:1589-96

Impact of Delays in Initiation of Antimicrobial Therapy for Septic Shock

Kumar A et al. Crit Care Med 2006;34:1589-96

Identifying Pneumonia

√ Fever√ Leukocytosis√ Purulent tracheal secretions√ New or persistent infiltrates√ Oxygenation√ Microbiology cultures

Effects of Inappropriate Initial Antimicrobial Therapy of Severe Sepsis

• 904 patients with severe sepsis or early septic shock

• Inappropriate antimicrobials in 211 (23%)

• Factors associated with inappropriate therapy:– Nosocomial infection– Infection with MDR pathogens– Fungal or polymicrobial infection

• Inappropriate therapy associated with increased mortality (OR 1.8, 95% CI 1.2-2.6)

39%

Harbarth S, et al. Am J Med 2003;115:529-535

Common Pathogens in Nosocomial Pneumonia

• Methacillin-resistant Staphylococcus aureus• Pseudomonas aeruginosa • Enteric gram- negative rods– Klebsiella sp.– Enterobacter sp.– Serratia sp.

• Acinetobacter sp.• Stenotrophomonas maltophilia

Am J Respir Crit Care Med 2006;171:388-416

Empiric Therapy for HCAP/VAP

OR OR

OR

OR

+

+

Am J Respir Crit Care Med 2006;171:388-416

MDMC Antibiogram

Guideline Recommendations• Begin IV antibiotics as early as possible and always within the first hour of

recognizing severe sepsis and septic shock

• Broad spectrum antimicrobial active against likely bacterial/fungal pathogens and with good penetration into lungs

• Consider combination therapy in Pseudomonas infections

• Combination therapy ≤ 3-5 days and de-escalation following susceptibilities

• Reassess antimicrobials daily to optimize efficacy, prevent resistance, avoid toxicity, and minimize costs

• Duration of therapy typically limited to 7-10 daysDellinger RP. Crit Care Med 2008; 36:296-327Am J Respir Crit Care Med 2006;171:388-416