Hospital Acquired Pneumonia (HAP)

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Hospital Acquired Pneumonia (HAP)

• By
• Professor Adel Khattab
• Prof. of Pulmonary Medicine
• Ain Shams University

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Definition

• This infection is with onset of 48-72
  hours of hospitalization, development of a new or
  progressive infiltrate in CXR, fever,
  leukocytosis and purulent tracheobronchial
  secretions.
• This infection was neither present nor
  incubating at the time of hospitalization.
• This definition, however may exclude cases
  that occur in outpatient settings or after
  discharge from the hospital.

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Definitions

• HAP refers to pneumonia that occurs ?48 hours
  after
• admission, which was not incubating at the time
  of
• admission.
• HAP is closely related share the same
  principles with
• Ventilator-associated pneumonia (VAP)
  Healthcare-
• associated Pneumonia (HCAP).
• VAP refers to pneumonia that arises more than
  4872
• hours after endotracheal intubation.
• (American Thoracic Society, 2005)

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Incidence of HAP

• 2nd most common nosocomial infection
• Rate 5-15 cases/ 1000 hospital admission
• ? 6- to 20-fold in mechanically ventilated
  patients
• Increases hospital stay by 7-9 days / patient
• Excess cost of more than 40,000 / patient
• Mortality rate is seriously high 30- 50
• VAP most vigorous type of nosocomial pneumonia
  occurs 927 of all intubated patients
• Mortality rate is seriously high 30-71

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Importance of Hospital Acquired Infection ( HAI )

• HAI are responsible for 44,000 to 98,000
  deaths annually and represent a cost of 17 to
  29 billion.

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Definitions

• Early-onset HAP VAP within the first 4 days of
• hospitalization.
• Late-onset HAP and VAP 5 days or more of
• hospitalization.
• (American Thoracic Society, 2005)

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Ventilator Associated Pneumonia (VAP )
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Prevalence of VAP

• VAP is a common disorder, with a prevalence of
  6-52 cases /100 patients depending on the
  population studied.
• Crude rate of VAP is usually 1-3 per day of
  intubation mechanical ventilation.
• Rates are greatly higher in surgical ICU patients
  than in medical ICU ones.

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Device Associated Infection Rates by Type of ICU
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Mortality of VAP

• Crude mortality rates for VAP ranges from 20-71
  , but deaths are often due to other causes in
  critically ill patients.
• A preferred measure is Attributable mortality
  ,defined as percentage of deaths that would not
  have occurred in the absence of infection.
• Attributable mortality of VAP ranges from 27-43

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Respiratory therapy equipment
Host factors
Invassive devices
Medications
Surgery
Gastric colonization
Oropharyngeal colonization
Aspiration Numbers of bacteria virulence
Lung Defenses Mechanical cellular/humoral
Translocation
Bacteremia
Pneumonia
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Sources of infection
Environment
Devices
Air aspergillus Water legionella Foodenteric
Gram -ve Fomites S. aureus RSV
Endotracheal tube Suction catheters Bronchosc
ope Respiratory therapy equipment Nasogastric tube
Other Patients
Staff
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Nosocomial pneumonia(NP)risk factors for
cross-transmission

• Increased risk for NP associated with poor
  hand-washing
• External colonization
• - Aerosol inoculation due to colonization of
  respiratory therapy
  equipment
• Nebulizers
• Mechanical ventilators
• Resuscitation bags and portable spirometers
• Inappropriate airway suctioning

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Respiratory therapy equipment
Host factors
Invassive devices
Medications
Surgery
Gastric colonization
Oropharyngeal colonization
Aspiration Numbers of bacteria virulence
Lung Defenses Mechanical cellular/humoral
Translocation ?
Bacteremia
Pneumonia
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Nosocomial pneumoniaClinical risk factors for
Oropharyngeal Colonization

• Coma
• Hypotension
• Renal failure
• Leucocytosis
• COPD
• Alcoholism

• Clinical underlying condition
• Period of hospitalization
• Nutritional status
• Antibiotic therapy
• Intubation
• ICU stay

Johanson et al, celis et al
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Respiratory therapy equipment
Host factors
Invassive devices
Medications
Surgery
Gastric colonization
Oropharyngeal colonization
Aspiration Numbers of bacteria virulence
Lung Defenses Mechanical cellular/humoral
Translocation ?
Bacteremia
Pneumonia
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Nosocomial pneumonia risk factors for gastric
colonization

• Advanced age .
• Achlorhydria.
• Alterations in gastric juice secretion.
• Antacids and H2 blockers.
• Increased concentration of conjugated bilirubin
  in gastric content.

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Respiratory therapy equipment
Host factors
Invassive devices
Medications
Surgery
Gastric colonization
Oropharyngeal colonization
Aspiration Numbers of bacteria virulence
Lung Defenses Mechanical cellular/humoral
Translocation ?
Bacteremia
Pneumonia
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Nosocomial pneumonia risk factors for aspiration

• Alterations of consciousness- Trauma, sedative
  drugs
• Nasogastric intubation
• Supine position
• Endotracheal tube
• - Direct pass to the lower airway- Leakage
  around the cuff- Bacterial biofilm/dislodgement
  to distal airway

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(American Thoracic Society, 2005)
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Microbiology of HAP

• Bacterial ( 80-90)
• - Gram ve bacilli (50-70)
• Pseudomonas aeruginosa
• Enterobacteriaceae
• Staphylococcus aureus (15-30)
• Anaerobic bacteria (10-30)
• Haemophilus influenzae (10-20)
• Streptococcus pneumoniae (10-20)
• Legionella speecies (4)

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Microbiology of HAP (con.)

• Viral (10-20 )
• - Cytomegalovirus
• - Influenza
• - Respiratory syncytial virus
• Fungal (lt 1 )

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Bacterial pathogens associated with HAP

• Early-onset HAP
• First 4 days
• Strept. pneumoniae.
• Hemophilus influenzae.
• Moraxella catarrhalis.
• Anaerobes (uncommon).

• Late-onset HAP
• After 4 days
• Pseudomonas aeruginosa.
• Acinetobacter.
• Enterobacter sp.
• MRSA.

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DIAGNOSTIC TECHNIQUES

• Blood, Pleural Fluid Analysis, and Culture
• Nonbronchoscopic evaluations
• Percutaneous needle aspiration
• Endotracheal aspiration
• Blind bronchial sampling
• Bronchoscopic techniques
• PSB
• BALTissue diagnosis

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Problems in Diagnosis of HAP

• Contamination by the upper airways Solved by
  protecting the sampling fluid.
• Separation of infection from colonization Solved
  by using quantitative cultures.

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Diagnostic strategies approaches

• HAP is suspected The presence of a new or
  progressive
• radiographic infiltrate plus at least two of
  three clinical
• features (fever gt38C, leukocytosis or leukopenia
  
• purulent secretions).
• Lower respiratory tract sample for microscopy
• culture from all patients, ideally before
  antibiotic started .
• Bronchoscopic or nonbronchoscopic.
• endotracheal aspirate (ETA), bronchoalveolar
  lavage (BAL),
• or protected specimen brush (PSB).
• Semi-quantitative or quantitative In
  quantitative cultures the diagnostic threshold
  is
• ETA 106 cfu/ml, BAL 104 or 105 cfu/ml, PSB 103
  cfu/ml.

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Hospitalized patient
No further Investigations observe
Clinical features Suggest Infection?
NO
Yes
Order/review recent CXR
Observe investigate for other sources
Abnormal ?
No
Yes
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Yes
Option A Quantitative culture
Option B Emperic treatment Qualitative culture
If clinically unstable
Nonbronchoscopic EA ,BAL ,PSB
Bronchoscopic BAL, PSB, PBAL
Adjust treatment According to Culture results
or Clinical response
Treat based on results Of diagnostic testing
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I will prevent disease whenever I can,
prevention is preferable to cure.Modem Versoin
(1964)
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Prevention of HAP

• (A) Regimens for specific indications
• Hand washing between patient contact.
• Pneumococcal and influenza vaccination for
  population at risk.
• Isolating patients with highly resistant
  organisms such as MRSA.

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It is not enough to produce satisfactory soap it
also necessary to induce people wash.
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Prevention of HAP

• (B) Regimens used widely in some clinical
  settings
• Nutritional support with careful attention to the
  route and volume of feeding.
• Intestinal bleeding prophylaxis, sucralfate
  compared with either antacids or H-2 blockers.
• Careful handling of ventilator tubing and
  associated equipments.
• Subglottic secretion drainage.
• Lateral rotation bed therapy.

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Prevention of HAP

• Intervention to decrease risk
• Single use non-sterile used for suction and
  change catheter between patients after each
  use.
• Single-use disposable or wash with detergent
• Single-use or disposable mouthpiece clean
  according to manufacture recommendations.

• Procedure or device
• Suction catheter
• Suction bottle
• Spirometry

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Prevention of HAP

• Breathing circuit
• Nebulizers Humidifiers

• Change MV circuit every 48 hours. Periodically,
  drain breathing-tube condensation trap, taking
  care not to spill it back to patient trachea.
• Change reprocess device between patients by
  sterilization or high level of disinfection
  fill with sterile water only.

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Classification of HAP Patients

• Is pneumonia mild to moderate or severe?
• Are specific host or therapeutic risk factors
  predisposing to specific pathogens present?
• Is pneumonia early onset (within 4 days of
  admission) or late onset?

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ATS DEFINITION OF SEVERE HAP

• Admission of ICU
• Resp. failure, defined as need for mechanical
  ventilation or the need for gt 35 oxygen to
  maintain an arterial oxygen saturation gt90
• Rapid radiographic multilobar pneumonia, or
  cavitation of a lung infiltrate
• Evidence of severe sepsis with hypotension and/or
  end-organ dysfunction
• Shock (systolic BP lt 90mmHg or diastolic Bp
  lt 60 mmHg) Requirement for vasopressors for gt 4 h
• Urine output lt20mL/h or total urine output
  lt80mL in 4 h(unless another explanation is
  available).
• Acute renal failure requiring dialysis

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(American Thoracic Society, 2005)
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(American Thoracic Society, 2005)
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(American Thoracic Society, 2005)
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previously
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• (American Thoracic Society, 2005)

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Duration of Therapy

• Efforts should be made to shorten the duration of
• therapy from the traditional 14 to 21 days to
  periods as
• short as 7 days, provided that the etiologic
  pathogen is
• not P. aeruginosa, and that the patient has a
  good
• clinical response with resolution of clinical
  features of Infection.

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• Control of antibiotic resistance requires
  aggressive implementation of several strategies
• 1- Ongoing surveillance of resistance.
• 2- when the rate of resistance increases using
  hygienic controls to limit spread of single
  (colonial)strains
• a-Hand hygiene (30-120 sec).
• b-Alcohol-based hand rubs (10-30 sec ).
• c-Use of disposable examination gloves during
  contacts with pts to decrease the problem of
  colonization pressure.

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• 3-Hospitals should use (closed formularies) for
  prescription of antibiotics to limit prescribing
  options to one or two drugs per class.
• 4-Restriction of the use of antibiotics has been
  effective in reducing cost and excessive empiric
  use of broad spectrum drugs .
• 5-Rotational use of antibiotics (antibiotic
  cycling program).

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• (American Thoracic Society, 2005)

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Clinical Resolution of HAP
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Clinical Pulmonary Infection Score

• For every item give score 0 ,1, 2 .
• For temperature normal 0 , up to 38.5 give 1,
  but if higher give 2 .
• Count the final score of all items if lt ,or 6
  means clinical resolution but if gt 6 means
  clinical unresolution and unimprovement.

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• (American Thoracic Society, 2005)

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Unresolved HAP

• Clinical re-assessment of the patient .
• Consider differential diagnosis .
• Exclude another site of infection ( UTI, vascular
  lines, bed sores, wounds).
• Re-collect another samples ( ET aspirate,
  bronchoscopic, pleural fluid, blood).
• Use multiple antibiotics instead of monotherapy.
• Consider steroids and open lung biopsy.

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THANK YOU