ESCMID eLibrary

26th ECCMID9-12 April 2016

Compendium of strategies to prevent healthcare-associated infections

Anastasia Antoniadou MD, PhDAssociated Professor

Internal Medicine-Infectious DiseasesNational and Kapodistrian University of Athens Medical School

University General Hospital ATTIKONESCMID eLibrary

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Conflicts of interest

Advisory boardsGILEAD, PFIZER, MSD

Ηonorarium for lecturesGILEAD, ViiV, BMS, MSD, ASTELLAS

Funding during the last 5 yearsGILEADNIH/INSIGHT

Support for participation in congressesGILEAD, BMS, ASTELLAS, PFIZERESCMID eLibrary

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Q1What is your specialty and everyday clinical practice?

1. Intensivist2. Infectious Diseases specialist3. Clinical microbiologist4. Internist5. Nurse6. Infection control practicioner

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Guidelines for the prevention of ventilator-associated pneumonia and their implementation. The Spanish “Zero-VAP” bundlePaquete de medidas para la prevención de la neumonía asociada a la ventilación mecánica y suaplicación en las UVI españolas. El Proyecto«Neumonía Zero» Medicina Intensiva 2013

2005

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History of guidelines for the prevention of VAP

1983 (Simmons et al AJIC)1997 (MMWR)2003 (MMWR)>2005 IHI’s initiative for saving 5 million lives from

unreliable care, endorsing a VAP prevention bundle2008 (SHEA, IDSA, AHA, APIC)2014 (SHEA,IDSA, AHA, APIC)

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New lung infection developing ≥48 hours after intubation and mechanical

ventilation

The Key event is intubation=

Intubation associated pneumoniaESCMID eLibrary

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VAP : epidemiology o VAP accounts for 300,000 cases of ICU-acquired infections each year in USAo22-47% of ICU infectionsoMultiplies the risk of death by 2-10 timesoCrude mortality 24-76% (attributed 10-13%)o Incidence 0.5-10.7/1000 ventilator-dayso 5-15% of ventilated patientsoIncreases LOS by 4-13 d (attributable 6)o The most costly hospital acquired infection (10-40,000 USD)

AJRCCM, 15 Feb 2005

Semin Resp Crit Care Med 2011

Melsen Lancet Infect Dis 2013

Waters Curr Opin Infect Dis 2015

ECDC REPORT 2007ESCMID eLibrary

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Prevention of ventilator-associated pneumonia (“intubation-associated” pneumonia) must be regarded as a critical mission

There is a need for multidimensional strategies combining effective surveillance, staff education, implementation of standard precautions measures and VAP prevention bundles

VAP preventive measures studied are numerous and some of them remain controversial

New surveillance definitions have been endorsed by the CDC in 2013

Updated guidelines for VAP prevention have been published in 2014ESCMID eLibrary

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“Traditional” definition (CDC)

VAP is usually defined by clinical, radiographic and microbiological criteria

New or persisiting lung infiltrative plus at least 2 of:Fever, leukocytosis or leucopenia and purulent secretions

For the microbiological diagnosis significant amount of bacteria in a quantitative or semiquantitative culture of tracheal secretions, BAL or PSBESCMID eLibrary

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“Traditional” definition (ECDC)

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“Traditional” definition (ECDC)

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Do you believe that VAP rates should be used as quality indicators for your patient’s quality of care and safety?

1. Yes2. No3. Probably4. I have no clue

Q2

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CID 2008

o No “gold standard” diagnosis

o No standardized severity scale

o Complex and often inaccurate surveillance methodESCMID eLibrary

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The weakness of traditional VAP surveillance, limit their utility for measuring the impact of care improvement programs and for benchmarking quality of care between different healthcare facilities

In 2011-2012, CDC developed a new approach of surveillance for mechanically ventilated patients in an attempt to overcome some of the limitations of traditional VAP surveillance

New surveillance definitions on board……

Klompas, ICHE 2014ESCMID eLibrary

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Infection and pneumonia is not the only complication related to intubation and mechanical ventilation

Improvement in quality of care necessitates surveillance of these complications (ARDS, pulmonary edema, atelectasis or pneumothorax)

Surveillance needs objective tools, measurable in a potentially easy, effective and reproducible way


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Objective definitions predicated on sustained increases in ventilator settings after a period of stability, detect a range of clinically significant events, including VAP, pulmonary edema, acute respiratory distress syndrome (ARDS), and atelectasis.

They consistently predict poor patient outcomes, including prolonged MV, increased length of stay and increased mortality

They are based on objective, quantitative, reproducible, comparable criteria and can be recorded in automated ways (electronic records)

Klompas, ICHE 2014ESCMID eLibrary

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3 DEFINITION TIERS

VACs

IVACs

Possible VAP and Probable VAP

Probable VAP is the closest proxy for “traditional”VAP

Abnormal temperature, or WBC plus new antibiotics

Purulent secretions plus positive culturesESCMID eLibrary

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Most VACs are due to pneumonia, pulmonary edema, atelectasis and ARDS. Strategies affecting the duration of MV, may be effective in lowering VACs


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Infection related VACESCMID eLibrary

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New surveillance definitions on board……Possible VAP is defined as Gram stain evidence of purulent pulmonary secretions or a pathogenic pulmonary culture in a patient with IVAC

Probable VAP is defined as Gram stain evidence of purulence plus quantitative or semiquantitative growth of a pathogenic organism beyond specified thresholds. Probable VAP can also be triggered by positive tests for respiratory viruses, Legionellaspecies, pleural fluid cultures, and suggestive histopathology with or without an abnormal Gram stain resultESCMID eLibrary

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VAE (VACs) were designed only for adult patientsVACs are currently the recommended by the CDC metric for

ventilated patientsVAC and IVAC are appropriate for public reportingPossible and probable VAP definitions are developed to be used

by healthcare facilities for internal quality improvementThe existing literature and guidelines for VAP prevention is the

best available tool to improve outcome for ventilated patientsExisting recommendations for VAP prevention have little data

regarding their impact on VAC and IVAC. May not be sufficient to reduce VAE rates


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Crit Care Med 2015

Multicentre database in France. 3028 patients with >5 days of MV77% at least 1 VAC29% at least 1 IVACGood correlation with pneumonia and antibiotic useESCMID eLibrary

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Is VAP by the familiar traditional definition a totally preventable event/complication?

1. YES2. NO3. It should be4. It is not possible to be

Q3

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Because of its importance and impact on morbidity in ICU patients, VAP prevention was included in the IHI campaign to save 100,000 (and 5 million) lives.Preventing measures in studies were able to reduce VAP rates. In USA there is a striking decline of VAP (4.9 to 1.4 events /1000 vent. days)Zero VAP for the moment is an “artifact” of the old surveillance definition (which has low sensitivity)

Klompas Curr Opin Infect Dis 2012ESCMID eLibrary

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Indicates modifiable factors at which prevention

measures are targetedESCMID eLibrary

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microorganisms

sources

Lung

oropharynx

Sinuses

Trachea

Gastric fluid

Tube (biofilm)

air

Water

Equipment

Inanimate environment

inhalationHematogenous

seeding Trraslocation

microaspiration

Underlying condition

Αntibiotics

Interventions

immunoparalysis

Health care personnel

Macroaspiration

Secretions

Indicates modifiable factors at which prevention

measures are targeted

colonization

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Colinization of the respiratory tract and the stomach is established rapidly after intubation

36 h...........mouth, pharynx

36-60 h......stomach

60-84 h......lower respiratory tract

60-96 h......the tube

Seeding of the lung by microaspirationESCMID eLibrary

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o3%/day the first 5 days post intubation

o2%/day 6-10 days post intubation

o1%/day 11-15 days post intubation

oDeclining incidence thereafter

AJRCCM, 15 Feb 2005

Defining event for the risk of VAP is intubation (X6-20 times)The risk is highest during the first week after intubation,

declining after day 10

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ADULT PATIENTS

GENERAL MEASURES

(SURVEILLANCE, INFECTION CONTROL)

BASIC PRACTICES

SPECIAL APPROACHES

GENERALLY NOT RECOMMENDED

NO RECOMMEN

DATION

OBJECTIVE OUTCOMES: oMV DURATIONoLOSoMORTALITYoCOST

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BASIC PRACTICES

Good evidence that the intervention decreases the average duration of mechanical ventilation, length of stay, mortality, and/or costs; benefits likely outweigh risks

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BASIC PRACTICES

1. Avoid intubation if possible by using NIPP [Quality of evidence(QE):high]Contraindications:impaired consiousness,ALI, ARDS, severe hypoxemia, severe acidemia, not rapid response to NIPP

2. Minimize sedation by managing patients without

sedation whenever possible, Interrupting sedation daily, Assessing readiness to extubate daily, Performing spontaneous breathing trials with sedatives turned off (QE=moderate to high)

3. Maintain and improve physical conditioning (provide early exercise and mobilization) (QE=moderate)(Balas et al Crit

Care Med 2014, Lord et al Crit Care Med 2013)ESCMID eLibrary

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BASIC PRACTICES

4. Minimize pooling of secretions above the endotracheal tube cuff

A. Utilize endotracheal tubes with subglotticsecretion drainage ports for patients expected to require greater than 48 or 72 hours of mechanical ventilation (QE=moderate)

A metaanalysis of 13 randomized trials showed 55% reduction in VAP. Less MV days, less LOS, antibiotic use and cost (Muscedere et al, Crit Care Med 2011)ESCMID eLibrary

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BASIC PRACTICES

4. Minimize pooling of secretions above the endotracheal tube cuff

B. Elevate the head of the bed to 30–45 degrees (QE=low)

Significant impact on VAP incidence, but Insufficient data at present to determine the impact of head-of-bed elevation on MV duration and mortality. Recommended because of simplicity, ubiquity, minimal risk, no cost and potential benefit (Alexiou et al , J Crit Care 2009: Metaanalysis of 3 trials with 337 patients)ESCMID eLibrary

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BASIC PRACTICES

5. Maintain ventilator circuits

Change the ventilator circuit only if visibly soiled or malfunctioning (QE= high) No impact on VAP, but decreases cost

Follow CDC/Healthcare Infection Control Practices Advisory Committee guidelines for sterilization anddisinfection of respiratory care equipment (QE=moderate)ESCMID eLibrary

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SPECIAL APPROACHES

A. Interventions that decrease duration of mechanical ventilation,length of stay, and/or mortality but for which insufficient data on possible harm

Selective decontamination of the oropharynx with topical antibiotics, or of the oropharync and digestive tract using a combination of topic, oral and parenteral antibiotics (decrease in mortality rates by 2.9-3.5% in Netherlands) QE=highESCMID eLibrary

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20095939 pts

Hospitals with high baseline rates of antibiotic resistance are advised to await the results of long-term studies of digestive decontamination in high-resistance environments before routinely adopting this strategy

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SPECIAL APPROACHES

B. Interventions that may lower VAP rates but for which there are insufficient data at present to determine their impact on duration of mechanical ventilation, length of stay, and mortality

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INTERVENTIONS QUALITY OF EVIDENCE

Regular oral care with chlorhexidine (16 RCTs, 9 metaanalysis, reduces 10-30% pneumonia in cardiac surgery patients)

Moderate

Prophylactic probiotics (4 metaanalysis, reduces VAP. Not in immunocompromised and GI diseases)

Moderate

Ultrathin polyurethane tube cuffs Low

Automated control of endotracheal tube cuff pressure Low

Saline instillation before tracheal suctioning Low

Mechanical tooth brushing LowESCMID eLibrary

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APPROACHES GENERALLY NOT RECOMMENDED

GENERALLY DEFINITELY

1. SILVER-COATED ENDOTRACHEAL TUBES(Kollef

JAMA 2008)2. KINETIC BEDS3. PRONE POSITIONING

1. STRESS ULCER PROPHYLAXIS2. EARLY TRACHEOTOMY3. MONITORING RESIDUAL

GASTRIC VOLUMES4. EARLY PARENTERAL

NUTRITIONESCMID eLibrary

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Approach neither recommended nor discouraged because it has no impact on VAP rates or patient outcomes and unclear impact on costs is the use of closed endotracheal tube suctioning systems (QE=moderate)

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General measures

Surveillance of VAP (VAC)Infection control measures (Hand hygiene, standard precautions, disinfection of equipment)Adequate staffing levelsOrotracheal intubation and endotracheal tube cuff pressure maintained at greater than 20 cm H2O to prevent leakageESCMID eLibrary

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Performance measures and implementation strategies

Surveillance and internal reportingMeasure compliance through process measure definitions and measurement strategies that may varyEducateEngage a multidisciplinary teamProvide feedback to staffESCMID eLibrary

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VAP bundles as implementation strategy

Bundles are recommended=a combination of critical process measures to enhance care. Processes may be synergisticThere is no consensus on which care processes to include in a VAP prevention bundleESCMID eLibrary

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Examples of VAP bundles: the SARI and Scottish proposed bundle1. Sedation reviewed and, if appropriate, stopped each

day.2. Patient assessed for weaning and extubation each day.3. Avoid supine position. Aim to have the head of bed

elevated to at least 30°.4. Use chlorhexidine as part of daily oral care (0.12-2.0%

applied 6-hourly).5. Use subglottic secretion drainage in patients likely to

be ventilated for more than 48 hours.ESCMID eLibrary

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1. Daily sedation vacation2. Silver coated endotracheal tubes3. Oral chlorhexidine care4. Elevation of the head of the bed5. Endotracheal tubes with subglottic secretions

drainage6. Selective decontamination of the digestive

tract

If you are asked to choose one of the following as the most crucial to include in your VAP bundle which would you choose?

Q3

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2016

An interdisciplinary group of clinical experts participated in a Delphi process, which wasguided by a technical expert panelAccording to guidelines a group of 65 possible interventions was recognized, narrowed to 19: 5 process and 14 structural measuresESCMID eLibrary

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Obtainingclinician input on what interventions to include

increases the likelihood that providers will adhere

to the bundle.ESCMID eLibrary

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VAP bundles as implementation strategy

Evidence on the impact of bundles is limited. Prevention bundles have been associated with variable reductions in VAP rates(40-70%). A smaller subset has been associated with improvements in objective outcomes.To date, however, prevention bundles have been tested only in observational before-after and time-series analyses rather than in randomized controlled trials.

Arch Surg 2010;145:465, BMJ Qual Saf 2011;20:811, CID 2010;51:1115, ICHE 2011;32:305ESCMID eLibrary

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A 7 elements bundle with high compliance(>90%) effectively and remarkably reduced VAP rates (from 8.6 to 2 /1000 vent. days), without affecting length of stay or mortality

2016

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1. Head-of-bed (HOB) elevation 30-452. Daily “sedation vacation” and daily assessment of readiness for extubation3. Peptic ulcer disease (PUD) prophylaxis4. Deep vein thrombosis (DVT) prophylaxis5. Oral care with chlorhexidine solution6. Adequate endotracheal tube cuff pressure (20-30 mmHg)7. Endotracheal tube with and in-line suction system andsubglottic suctioning.

A 7 element VAP bundle

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Intubation and mechanical ventilation put the patients in high risk of complications, one of which is ventilator associated pneumonia, with high morbidity, considerable mortality and cost

Current VAP definitions are subjective, not specific and limit the value of VAP surveillance as a benchmark of improving patient care

New definitions have been proposed after 2012 by the CDC, recording Ventilation associated Events or Conditions, based on alteration of patient’s oxygenation and ventilator’s indications ESCMID eLibrary

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VAP possible and probable are a subgroup of Infectious VACs

They should be recorded only for internal quality assessment

VAP prevention guidelines, recently updated in USA, are referred to VAP defined by the old, traditional definitions, aiming at reducing not only VAP incidence, but mainly objective outcome measures: duration of MV, length of hospital stay, mortality and costESCMID eLibrary

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A measure is recommended for the prevention of VAP, if by high or moderate quality evidence can record a change in objective outcome measures

General, Basic and Special strategies are included in the guidelines, based on modifiable risk factors for VAP

Implementation strategies are also discussed. VAP bundles are yet to be proved if they will be the most effective implementation strategy, and no consensus exists about which and how many processes to include in a bundleESCMID eLibrary

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Documents

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