Prevention of Ventilator Associated Pneumonia

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Prevention of Ventilator Associated Pneumonia

• Safe Critical Care Project
• Vanderbilt-HCA Collaborative

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Ventilator Associated Pneumonia (VAP) - Key
Points -

• VAP is the 2nd most common nosocomial infection
  15 of all hospital acquired infections
• Incidence 9 to 70 of patients on ventilators
• Increased ICU stay by several days
• 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

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Challenge and Controversy

• There is no doubt that the diagnosis and
  management of VAP remains one of the most
  controversial and challenging topics in
  management of critically ill patients.

Chan C, Chest 2005127425
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Changing Views of VAP

• No longer just an unfortunate occurrence
• Viewed as medical error
• Institute of Medicine
• Leapfrog Group
• JCAHO hospitals required to show VAP
  prevention/reduction measures

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Diagnosing VAP

• VAP is a Nosocomial Pneumonia Hospital acquired
  
• Diagnosis is imprecise and usually based on a
  Combination of
• Clinical factors - fever or hypothermia change
  in secretions cough apnea/bradycardia
  tachypnea
• Microbiological factors - positive cultures of
  blood/sputum/tracheal aspirate/pleural fluids
• CXR factors - new or changing infiltrates

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DiagnosingVAP

• Diagnosis of VAP can be a confusing and
  complicated process.
• In order to clarify the process and help
  clinicians, the Centers for Disease Control and
  Prevention (CDC) published guidelines for
  diagnosing VAP in 2003 Guidelines for
  Preventing Health-Care--Associated Pneumonia,
  2003 http//www.cdc.gov/mmwr/preview/mmwrhtml/rr
  5303a1.htm
• These guidelines were revised and updated in a
  joint statement published by the American
  Thoracic Society and the Infectious Diseases
  Society of America
• Am J Respir Crit Care Med 171388-416, 2005

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Diagnosing VAP

• For this project, we used the revised guidelines
  to developed tools to help clinicians with making
  the diagnosis.

Am J Respir Crit Care Med 171388-416, 2005
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Bad Bugs Pathogens in VAP (1)

• Pathogens that cause VAP differ depending on
  whether the condition occurs early (less than 96
  hours after intubation or admission to ICU) or
  late (greater than 96 hours after intubation or
  admission to ICU)

Kollef M, Chest 20051283854-62
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Bad Bugs Pathogens in VAP (2)

• EarlyOnset Pneumonia (lt 96 hours of intubation
  or ICU admission)
• Community-acquired
• Pathogens
• Streptococcus pneumoniae
• Haemophilus influenzae
• Staphylococcus aureus
• Antibiotic-sensitive

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Bad Bugs Pathogens in VAP (3)

• Late-Onset Pneumonia (gt 96 hours of intubation or
  ICU admission)
• Hospital-acquired
• Pathogens
• Pseudomonas aeruginosa
• Methicillin resistant Staphylococcus aureus
  (MRSA)
• Acinetobacter
• Enterobacter
• Antibiotic-resistant

Kollef M, Chest 20051283854-62
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Risk Factors for Nosocomial Pneumonia

• Major risk factor mechanical intubation
• Factors that enhance colonization of the
  oropharynx /or stomach
• Administration of antibiotics
• Admission to ICU
• Underlying chronic lung disease
• Conditions favoring aspiration into the
  respiratory tract or reflux from GI tract
• Supine position GERD
• NGT placement Coma/delirium
• Intubation and self-extubation
• Immobilization
• Surgery of head/neck/thorax/upper abdomen

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Risk Factors for Nosocomial Pneumonia (contd)

• Conditions requiring prolonged use of mechanical
  ventilatory support with potential exposure to
  contaminated respiratory devices /or contact
  with contaminated hands
• Host Factors
• Extremes of age
• Malnutrition
• Immunocompromised
• Underlying condition/disease process

Cook D et al, Ann Intern Med 1998129433-40
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Diagnosing VAP using flow diagrams as guides

• Four diagrams
• Algorithm 1 Adolescents and adults
• Algorithm 2 Immunocompromised pt.
• Algorithm 3 Children 1 to lt12 years
• Algorithm 4 Infants (lt1 year)

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Algorithm 2 Diagnosing VAP in Immunocompromised
Patients
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Algorithm 3 Diagnosing VAP in Children (Age gt1
and lt13 years)
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Algorithm 4 Diagnosing VAP in Infants (Age lt1
year old)
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VAP Antibiotic Selection(introductory comments)

• Considerations in making selection
• Setting (community, NH, hospital)
• Suspected organism (GNRs, GPCs)
• Host factors (immunosuppression)
• Local susceptibility patterns
• Initial empiric and broad subsequent narrowing
• Concept is to not miss the organism with initial
  coverage and then de-escalate when able

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Selected references

• Centers for Disease Control and Prevention
  Guidelines for Preventing Healthcare-Associated
  Pneumonia, 2003, http//www.cdc.gov/mmwr/preview
  /mmwrhtml/rr5303a1.htm
• Cook D et al. Incidence of and risk factors for
  ventilator-associated pneumonia in critically ill
  patients. Ann Intern Med 1998 Sep
  15129(6)433-40.
• Dodek, P and the Canadian Critical Care Trials
  Group. Evidence-based clinical practice guideline
  for the prevention of ventilator-associated
  pneumonia. Ann Intern Med. 2004 Aug
  17141(4)305-13.  
• Guidelines for the management of
  hospital-acquired, ventilator-associated and
  healthcare-associated pneumonia. Joint statement
  the American Thoracic Society and the Infectious
  Diseases Society of America. Am J Respir Crit
  Care Med 2005, 171388-416.
• Kollef M, epidemiology and outcomes of
  healthcare-associated pneumonia results from a
  large US database of culture-positive pneumonia.
  Chest 2005,1283854-62.
• Langley JM, Bradley JS. Defining pneumonia in
  critically ill infants and children. Pediatr Crit
  Care Med 2005, 6supplementS9-S13.
• Rumbak, M. J. Strategies for prevention and
  treatment. Journal of Respiratory Diseases, 2000,
  21(5)321-327.

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Ventilator associated Pneumonia

• Next webcast will focus on Ventilator Bundle
• Interventions to prevent or reduce VAP
• Check lists to help the patient care team
• Discussion of antibiotic choices
• Webcast