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Prevention of Ventilator Associated Pneumonia

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Surgery of head/neck/thorax/upper abdomen. Risk Factors for. Nosocomial Pneumonia (cont'd) ... to contaminated respiratory devices &/or contact with ... – PowerPoint PPT presentation

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Title: Prevention of Ventilator Associated Pneumonia


1
Prevention of Ventilator Associated Pneumonia
  • Safe Critical Care Project
  • Vanderbilt-HCA Collaborative

2
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

3
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4
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
5
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

6
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

7
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

8
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
9
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
10
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

11
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
12
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

13
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
14
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)

15
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16
Algorithm 2 Diagnosing VAP in Immunocompromised
Patients
17
Algorithm 3 Diagnosing VAP in Children (Age gt1
and lt13 years)
18
Algorithm 4 Diagnosing VAP in Infants (Age lt1
year old)
19
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

20
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.

21
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
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