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Hospital Acquired PneumoniaHospital Acquired PneumoniaHospital Acquired PneumoniaHospital Acquired Pneumonia
Pneumonia that occurs 48 hrs or more after admission, which was not incubating at the time of admission.
Hospital Acquired PneumoniaHospital Acquired PneumoniaHospital Acquired PneumoniaHospital Acquired Pneumonia
American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.
Epidemiology Common hospital-acquired infection 25% of all ICU acquired infections 2nd most common type of nosocomial infection after UTI. Incidence increases by 6-20 fold in patients being ventilated
mechanically. Occurs at the rate of 5-10 cases per 1000 hospital
admissions
Hospital Acquired PneumoniaHospital Acquired PneumoniaHospital Acquired PneumoniaHospital Acquired Pneumonia
American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.
Hospital Acquired PneumoniaHospital Acquired PneumoniaHospital Acquired PneumoniaHospital Acquired Pneumonia
American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.
Epidemiology Associated with substantial morbidity Has an associated crude mortality of 30-70% In ICU nearly 90% episodes of HAP occur during
mechanical ventilation. Hospital stay increases by 7-9 days per patient Produce an excess cost of more than $40,000 per
patient
Pneumonia developing in a patient receiving mechanical ventilation for longer than 48–72 hours after tracheal intubation. [1]
What is VAP?What is VAP?What is VAP?What is VAP?
American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.
Ventilator Associated Pneumonia (VAP) – Key Points -Ventilator Associated Pneumonia (VAP) – Key Points -Ventilator Associated Pneumonia (VAP) – Key Points -Ventilator Associated Pneumonia (VAP) – Key Points -
VAP is 15% of all hospital acquired infections Incidence = 9% to 27% of patients on ventilators Increased avg. hospital stay 1 to 3 weeks Mortality = 13% to 55% Added costs of $40,000 - $50,000 per stay
Centers for Disease Control and Prevention, 2003. Rumbak, M. J. (2000). Strategies for prevention and treatment. Journal of Respiratory Disease, 21 (5), p. 321;
Risk of VAP is highest early in the course of hospital stay, and is estimated to be
3%/day during the first 5 days of ventilation,
2%/day during Days 5 to 10 of ventilation, and
1%/day thereafter
Ventilator Associated Pneumonia (VAP) – Key Points -Ventilator Associated Pneumonia (VAP) – Key Points -Ventilator Associated Pneumonia (VAP) – Key Points -Ventilator Associated Pneumonia (VAP) – Key Points -
American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.
Hospital Acquired PneumoniaHospital Acquired PneumoniaHospital Acquired PneumoniaHospital Acquired Pneumonia
Pathogenesis
PathogenesisInvasion of the lower respiratory tract by:
Aspiration of oropharyngeal/GI organisms
Inhalation of aerosols containing bacteria
Hematogenous spread
Hospital Acquired PneumoniaHospital Acquired PneumoniaHospital Acquired PneumoniaHospital Acquired Pneumonia
MMWR, January 3,1997/vol.46/No.RR-1
Microaspiration may occur in up to 45% of healthy volunteers during sleep
Oropharynx of hospitalized patients is colonized with various pathogenic bacterias depending on the severity and type of underlying illness
Multiple factors are associated with higher risk of colonization with pathogenic bacteria and higher risk of aspiration
MMWR, January 3,1997/vol.46/No.RR-1
Hospital Acquired PneumoniaHospital Acquired PneumoniaHospital Acquired PneumoniaHospital Acquired Pneumonia
MMWR, January 3,1997/vol.46/No.RR-1
Pathogenesis
Colonization Aspiration
HAPHAPHAPHAP
MRSA*
Intubation & mechanical ventilation Supine positioning Inadequate infection control practices Inadequate surveillance of ICU infections Nasal intubation Emergent or re-intubation Underlying pulmonary disease Enteral feeding
Risk FactorsRisk FactorsRisk FactorsRisk Factors
American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.
Antimicrobial therapy in the preceding 90 days Current hospitalization for >5 days or recent hospitalization
(<90 days) High rate of antibiotic resistance in hospital or ward Transfer from nursing home or rehab center Hospitalization for 2 days or more in the preceding 90 days Home infusion therapy (including antibiotics) Family member with multidrug – resistant pathogen Immunosuppressive disease and/or therapy
Risk Factors for MDR Pathogens Causing HAP/ VAPRisk Factors for MDR Pathogens Causing HAP/ VAP
American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.
Early onset VAP occurs on day 1-4 of intubation Late onset occurs on or after day 5 Early onset often associated with more pan-sensitive,
endogenous pathogens and has a better prognosis Late onset often associated with multi-drug resistant
pathogens (MDRs) and has poorer prognosis Patients recently hospitalized or transferring from an
extended care facility are more likely to harbor resistant pathogens
Early Vs. Late Onset VAPEarly Vs. Late Onset VAP
American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.
Avoid intubation by using noninvasive ventilatory support
Shorten intubation period with switch to noninvasive ventilatory support
Inflate pilot balloon to 20 mm to diminish aspiration of subglottic secretions
Remove subglottic secretions by periodic oral suctioning or by employing double-lumen catheter with continuous subglottic suction
Preventive StrategiesPreventive Strategies
American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.
Head of bed elevation to 30 – 45 degrees demonstrated a threefold reduction in the incidence of ICU – acquired HAP.
Orally intubate; nasal intubation prevents drainage of sinuses, increasing risk of sinusitis and VAP
Use oro-gastric instead of nasal-gastric tube for gastric drainage/nutrition
Check gastric residual and prevent distention
More Preventive StrategiesMore Preventive StrategiesMore Preventive StrategiesMore Preventive Strategies
American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.
Minimize use of antibiotics to decrease selection pressure on resident flora that produces MDR’s
Tightly control glucose levels to reduce risk of infection
Provide optimal nutrition early – TPN vs. enteral
American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.
More Preventive StrategiesMore Preventive StrategiesMore Preventive StrategiesMore Preventive Strategies
* 43 series (3650 episodes) 1984 – 2003, etiology confirmed by blood, BAL or PSB cultures
Luna CM et al. Archiv Bronconeumol 2005;41: 439
Common Pathogens of VAPCommon Pathogens of VAPCommon Pathogens of VAPCommon Pathogens of VAP
25%
20%
15%
10%
5%
0%P. aeruginosa Acinetobacter
spp
GNEB Haemophilus S. aureus S. Pneumoniae Other
Pathogens of VAP in different World AreasPathogens of VAP in different World AreasPathogens of VAP in different World AreasPathogens of VAP in different World Areas
Luna CM et al. Archiv Bronconeumol 2005;41: 439
USA Europe Latin America
25%
20%
15%
10%
5%
0%
30%
S. aureus
P. Aeruginosa
Acinetobacter spp
S. Maltophilia
Enterobacteriaceae*Haemophilus spp
Objective2
Objective1
Avoid the emergenceof multidrug-resistant
microorganisms
Immediate Rx. of patients with VAP
TreatmentTreatmentTreatmentTreatment
HAP treatment recommendations was published in 2008 for Asian Countries
by Asian HAP Working Group
HAP & VAP are difficult to treat serious infections Many treatment options available ATS/IDSA guidelines may not be applicable in
Asian scenario Different clinical practices in Asian countries:
Availability of specific antibiotics & formulations Difference in cost of antibiotics
Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92
Need for Asian HAP GuidelinesNeed for Asian HAP GuidelinesNeed for Asian HAP GuidelinesNeed for Asian HAP Guidelines
Other factors: different epidemiologic, etiologic and resistance
patterns (markedly higher incidences of MRSA & MDR pathogens in Asia)
Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92
Need for Asian HAP GuidelinesNeed for Asian HAP GuidelinesNeed for Asian HAP GuidelinesNeed for Asian HAP Guidelines
To address these issues the Asian – Pacific Research Foundation for Infectious Diseases, together with the Asian Network for Surveillance developed consensus treatment recommendations for HAP in Asian Countries based on the current epidemiologic situation in the asia.
To address these issues the Asian – Pacific Research Foundation for Infectious Diseases, together with the Asian Network for Surveillance developed consensus treatment recommendations for HAP in Asian Countries based on the current epidemiologic situation in the asia.
Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92
The first working group meeting held in Kuala Lumpur, Malaysia and brought together physician from 10 Asian countries (Malaysia,
Thailand, Shina, South Korea, India, Taiwan, Hong Kong, Pakistan, Philippines and Singapore).
The first working group meeting held in Kuala Lumpur, Malaysia and brought together physician from 10 Asian countries (Malaysia,
Thailand, Shina, South Korea, India, Taiwan, Hong Kong, Pakistan, Philippines and Singapore).
Methodology AdoptedMethodology AdoptedMethodology AdoptedMethodology Adopted
Reviewed Existing governmental & institutional guidelines in Asian
Countries (only few Asian countries have guidelines ATS/ IDSA guidelines International epidemiologic data National or Local data from the 10 Asian countries
representatives Information regarding clinical practices in Asian
countries.
Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92
Indian Panel MembersIndian Panel MembersIndian Panel MembersIndian Panel Members
Indraprastha Apollo hospital SGR Hospital Christian Medical College
Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92
HAP working Group ObservationsHAP working Group ObservationsHAP working Group ObservationsHAP working Group Observations
Knowledge gaps between evidence or data on epidemiology, etiology, and antibiotic resisitance of pathogens causing HAP and VAP in Asian countries
Evidence based recommendations difficult to implement because of fewer data
Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92
Treatment RecommendationsTreatment RecommendationsTreatment RecommendationsTreatment Recommendations
Initial Approach to Empirical TherapyInitial Approach to Empirical TherapyInitial Approach to Empirical TherapyInitial Approach to Empirical Therapy
HAP or VAP Suspected
Evaluation• Risk Factors for MDR pathogen• Time of onset (early or late )• Local microbiologic data and resistance pattern• Patient status• LRT sample Gram Stain• Allergy to medication• Underlying co-morbidities• Formulary restrictions• Cost
Select Empirical Antibiotic therapy
Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92
Initial Empiric Antibiotic treatment for early onset HAP Initial Empiric Antibiotic treatment for early onset HAP (Table I)(Table I)Initial Empiric Antibiotic treatment for early onset HAP Initial Empiric Antibiotic treatment for early onset HAP (Table I)(Table I)
Potential Pathogen Recommended Regimen* Strep. Pneumoniae$ H. Influenza MSSA Antibiotic – sensitive enteric Gram
–ve bacilli: E coli K. pneumoniae Enterobacter sp. Proteus sp. S. marcescens
3rd generation cephalosporins (ceftriaxone, cefotaxime) or Fluoroquinolones (moxifloxacin, levofloxacin) or ß-lactum/ß-lactamase inhibitor (amoxicillin/clavulanic acid; ampicillin/
sulbactum) or Carbepenms (ertapenem) or 3rd generation cephalosporins + macrolide or monobactum + clindamycin (for ß-lactum – allergic patients
*Antibiotic options should depend on local epedimiology of etiologic pathogens.$ The frequency of macrolide-resistant S. pneum and MDR S pneum is increasing; levofloxacin or moxifloxacin ae preferred to ciprofloxacin and the role of other new quinolones has not been established.
Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92
Initial Empiric Antibiotic treatment for late onset HAP Initial Empiric Antibiotic treatment for late onset HAP (Table II)(Table II)Initial Empiric Antibiotic treatment for late onset HAP Initial Empiric Antibiotic treatment for late onset HAP (Table II)(Table II)
Potential Pathogen Recommended RegimenPathogens Listed in table I and MDR pathogens Pseudomonas aeruginosa K. pneumoniae (ESBL+) *
Acinetobacter sp. *
MRSA
Legionella pneumophilia *
Antipseudomonal cephalosporins (cefepime, ceftazidime) or Antipseudomonal carbepene (imipenem or meropenem) or ß-lactum/ß-lactamase inhibitor (piperacillin - tazobactum) +/- Fluoroquinolone (ciprofloxaccin or levofloxacin) or Aminoglycoside (amikacin, gentamicin or tobramycin)
Cefoperazone / sulbactum + fluoroquinolones or aminoglycosides + ampicillin/ sulbactum (if sulbactum is not available
or Fluoroquinolones(ciprofloxacin) + aminoglycoside + linezolid or glycopeptide
(vancomycin or teicoplanin)$ + azithromycin of fluoroquinolone
*if an ESBL strain such as K. pneum or an Acinetobacter sp. Is suspected the a carpenem is a reliable choice. If L. pneumophilia is suspected then the combination antibiotic regimen should include a macrolide (eg. Azithromycin) or a fluoroquinolone (eg. Ciprofloxacin or levofloxacin) should be used rather than an aminoglycoside.$ If MRSA risk factors are presenr or there is a high incidence locally.
Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92
Initial Empiric Antibiotic treatment for early onset VAP Initial Empiric Antibiotic treatment for early onset VAP (Table III)(Table III)Initial Empiric Antibiotic treatment for early onset VAP Initial Empiric Antibiotic treatment for early onset VAP (Table III)(Table III)
Potential Pathogen Recommended RegimenPathogens Listed in table I and MDR
pathogens Pseudomonas aeruginosa K. pneumoniae (ESBL+)
Acinetobacter sp.
MRSA
Antipseudomonal cephalosporins (cefepime) or Antipseudomonal carbepene (imipenem or meropenem) or ß-lactum/ß-lactamase inhibitor (piperacillin – tazobactum) +/- Fluoroquinolone (ciprofloxaccin or levofloxacin) or Aminoglycoside (amikacin, gentamicin or tobramycin) +/- Linezolid or glycopeptide ( vancomycin or teicoplanin)
Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92
Initial Empiric Antibiotic treatment for late onset HAP Initial Empiric Antibiotic treatment for late onset HAP (Table IV)(Table IV)Initial Empiric Antibiotic treatment for late onset HAP Initial Empiric Antibiotic treatment for late onset HAP (Table IV)(Table IV)
Potential Pathogen Recommended RegimenMDR pathogens Pseudomonas aeruginosa K. pneumoniae (ESBL+)
Acinetobacter sp.
MRSA
Antipseudomonal carbepene (imipenem or meropenem) or ß-lactum/ß-lactamase inhibitor (piperacillin - tazobactum) +/- Fluoroquinolone (ciprofloxaccin or levofloxacin) or Aminoglycoside (amikacin, gentamicin or tobramycin) +/- Linezolid or glycopeptide ( vancomycin or teicoplanin)
Cefoperazone / sulbactum + fluoroquinolones or aminoglycosides + ampicillin/ sulbactum (if sulbactum is not available +/- Linezolid or glycopeptide ( vancomycin or teicoplanin) or Fluoroquinolones(ciprofloxacin) + aminoglycoside +/- linezolid or glycopeptide (vancomycin or teicoplanin)
Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92
Treatment Recommendations for Treatment Recommendations for MDR pathogensMDR pathogens
Treatment Recommendations for Treatment Recommendations for MDR pathogensMDR pathogens
MRSAMRSAMRSAMRSA
First line treatment : Teicoplanin or Vancomycin. Teicoplanin as compared to Vancomycin has fewer
side effects and does not require serum monitoring levels.
Linezolid to be reserved as second tier agent.
Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92
P. AeruginosaP. AeruginosaP. AeruginosaP. Aeruginosa
First line : Piperacillin/ tazobactum or carbapenems +/- aminoglycosides or fluoroqinolone
Fluoroqinolones offer theoretical advantage of improved bioavailability in respiratory tract.
Ciprofloxacin or Levofloxacin Fluoroqinolones preferred in combination therapy
In unresponsive patients Polymyxin B or Colistin in combination with fluoroqinolone
Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92
Acinetobacter sp.Acinetobacter sp.Acinetobacter sp.Acinetobacter sp.
First Line: Cefoperazone/ sulbactam and/or tigecycline Sulbactam an enzyme inhibitor has direct activity against
Acinetobacter. In unresponsive patients : Polymyxin B or Colistin
Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92
Antibiotic regimens against specific antibiotic – Antibiotic regimens against specific antibiotic – resistant pathogensresistant pathogensAntibiotic regimens against specific antibiotic – Antibiotic regimens against specific antibiotic – resistant pathogensresistant pathogens
Pathogen Antibiotic Regimen
MRSA 1.Vancomycin or Teicoplanin2.Linezolid or tigecycline
MDR Pseudomonas Aeruginosa
1.Piperacillin/ tazobactum or carbapenems +/- aminoglycosides or fluoroqinolone
2.Polymixin B or Colistin
MDR Acinetobacter 1.Cefoperazone/ sulbactam and/or tigecyclinne2.Polymyxin B or Colistin
ESBL + K. pnumoniae 1.Carbapenems or tigecycline2.Piperacillin/ Tazobactam
ESBL + E. Coli 1.Carbapenems or tigecycline2.Piperacillin/ Tazobactam
Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92
Duration of TreatmentDuration of TreatmentDuration of TreatmentDuration of Treatment
Asian HAP Working Group recommends the initial empirical antibiotic treatment should continue for 7 to 14 days.
If MDR pathogen is identified then the treatment may be continued for up to 14 days.
Patient response should be evaluated frequently with consideration given to de-escalating therapy when appropriate.
Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92
Role of Teicoplanin
Glycopeptide antibiotics teicoplanin and Vancomycin is the First line therapy
against Nosocomial Pneumonia attributable to MRSA.
Teicoplanin in Nosocomial PneumoniaTeicoplanin in Nosocomial Pneumonia
Hunter J D Postgrad Med J 2006; 82: 172-178
ConclusionsConclusionsConclusionsConclusions
HAP/ VAP is one of the more frequent causes of nosocomial infection and the first one causing death.
MRSA incidence is on rise. MRSA is one of the most common cause of HAP/ VAP No definite guidelines present in Asian countries for
HAP/VAP ARFID & ANSORP recommended treatment for HAP/VAP Teicoplanin is the First line therapy in MRSA HAP/VAP
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