Beware of a black cat that crosses your path

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Beware of a black cat that crosses your path
Case 2 Prevention
2
History

• 78 year old female
• Tripped over her cat at the top of the stairs
• Presented to the Emergency Department complaining
  of pain in her right leg
• No significant past medical history
• Normally independent, fit and well
• Lifelong non-smoker
• Had been prescribed an anti-hypertensive agent in
  the past, but didnt take it

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Examination

• Shortened, externally rotated, painful right leg
• Bruises on left arm and small laceration left
  shin
• Afebrile, pulse 100 (regular), blood pressure
  120/70
• Loud pansystolic murmur best heard at apex
• Good air entry both lungs, O2 saturation 96 on
  air

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What investigations would you perform?

• Chest X-ray
• Pelvis X-Ray
• Transthoracic Echocardiogram
• Full Blood Count
• Urea and Electrolytes
• All of the above

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Initial X-Rays
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Initial X-Rays
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Results

• FBC Hb 9.4 g/dL, wbc 11.9, plts 243 (x109/L)
• UE Na 144, K 3.3, creatinine 47 µmol/L
• CRP 9 mg/L (normal range 0-6)

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Results

• Echocardiogram report
• Normal LV with hyperdynamic function
• LA mildly dilated
• MV leaflets sclerotic with dense echogenic mass
  at tip and moderate/severe mitral regurgitation
• AV normal
• Mild PV and TV regurgitation
• Moderate to severe pulmonary hypertension

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Follow-up

• Surgery is delayed while the cardiac status is
  reviewed
• Endocarditis is considered and eventually
  excluded on grounds of lack of clinical signs or
  inflammatory response and negative blood cultures
• On day 9 of admission a right Austin Moore
  hemiarthroplasty is performed with flucloxacillin
  perioperative prophylaxis
• The anaesthetic assessment notes that she is a
  high anaesthetic risk in view of her mitral valve
  disease and pulmonary hypertension

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Follow-up

• On day 16 of admission she becomes breathless.
  She is hypotensive (bp 90/60) and has a fever of
  38ºC.
• On examination she is found to be in fast atrial
  fibrillation and to have reduced air entry at the
  right lung base.
• Benzylpenicillin and ciprofloxacin are commenced

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Results

• CRP 235 mg/L (normal 0-6)
• FBC Hb 10.9 g/dL
• wbc 17.3 x 109/L (normal 4-11)
• neutrophils 12.8 x 109/L (normal 2-7.5)
• lymphocytes 1.0 x 109/L (normal 1.5-4)
• monocytes 2.9 x 109/L (normal 0.2-0.8)
• Film comment occasional reactive lymphocyte seen

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Chest X-Ray Day 16
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Follow-up

• On day 17 of admission she is sweaty and clammy.
• Her respiratory rate is 42/minute and her O2
  saturation 86 on air. She has widespread wheeze
  and crackles throughout both lungs
• The medical registrar considers that she is
  clearly septic and she is transferred to the ICU

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What would you do next?

• Ensure that she is in a side room with negative
  pressure ventilation?
• Perform bronchoscopy and bronchoalveolar lavage
  (BAL)?
• Provide ventilatory support?
• Change antibiotic therapy?

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Follow-up

• On admission to the ICU she is noted to have a
  fruity cough and bronchial breathing at both
  lung bases
• She has a temperature of 37.5ºC and her O2
  saturation is 85 on 90 humidified oxygen. She
  is cardioverted into sinus rhythm and given
  inotrope support
• A diagnosis of pulmonary oedema and sepsis is
  made. Respiratory tract infection is considered
  the most likely source

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What antibiotic regimen (if any) would you
prescribe initially?

• Continue benzylpenicillin and ciprofloxacin
• Carbapenem alone
• Carbapenem plus glycopeptide
• Betalactam/cephalosporin alone
• Betalactam/cephalosporin plus glycopeptide
• Betalactam/cephalosporin plus macrolide
• Other

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Initial tests and treatment

• BAL immunofluorescence positive for
  parainfluenzavirus type 3 on two separate
  specimens taken on consecutive days
• Bacterial cultures are all negative

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What would you do next?

• Ensure that she is in a side room with negative
  pressure ventilation?
• Change antibiotic therapy?
• Continue current management?
• Other?

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Follow-up

• She is breathing without ventilatory support
  until day 19 of her admission when she becomes
  very tired and finally is intubated
• On initial ICU admission benzylpenicillin plus
  ciprofloxacin are continued. These are stopped
  after 5 days in view of the BAL findings
• She is moved into a side room with negative
  pressure ventilation to prevent spread of
  parainfluenzavirus type 3 to other patients

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Chest X-Ray Day 21
21
Follow-up

• After initial improvement between day 21 and day
  28 of admission she is noted to have a fever of
  38ºC and increasing production of thick brownish
  sputum
• The white cell count is raised at 13.4 x 109/L
  and the CRP is high, but little changed at 93
  mg/L
• Bronchoscopy reveals numerous plugs of mucus in
  the right middle and lower lobe

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Chest X-Ray Day 28
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CT Scan Day 29
Bilateral pleural effusions
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What is your diagnosis?
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What antibiotic regimen (if any) would you
prescribe?

• Quinolone alone
• Quinolone plus glycopeptide
• Carbapenem alone
• Carbapenem plus glycopeptide
• Betalactam/cephalosporin alone
• Betalactam/cephalosporin plus glycopeptide
• Betalactam/cephalosporin plus macrolide
• Other

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Subsequent tests

• BAL
• Numerous pus cells seen on microscopy
• Culture Klebsiella pneumoniae gt105 cfu/mL
• Resistant to ampicillin, ciprofloxacin,
  gentamicin, cefotaxime and ceftazidime
  (ESBL-positive)
• Susceptible to meropenem

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Follow-up

• She is treated with vancomycin and meropenem for
  10 days and makes a slow improvement
• Bronchoscopy is repeated on three occasions to
  remove mucus plugs
• She is slowly weaned onto non-invasive
  ventilation (NIPPV), but makes very slow progress
• She is still in the ICU on day 72 of admission

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What do you consider to be the key issues in this
case?

• Why did this lady develop pneumonia?
• What else could have been done?

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Key issues
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Prevention Four broad categories

• General
• Equipment
• Patient procedures
• Environmental issues

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I - General issues
Vaccination
Education guidelines
Hand hygiene and other infection control practices
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II Equipment maintenance and disinfection
Ventilator humidifiers and circuits
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III Patient procedures
Line insertion
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IV Environmental issues
Building work, fungal prophylaxis, environmental
sampling
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Grade A Recommendations (1)

• Care protocols and guidelines for weaning and
  sedation should be developed and actively
  followed in the critical care setting to reduce
  the incidence of VAP
• Changing ventilator circuits before seven days is
  of no benefit
• Daily changes of suction equipment are not
  required

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A Recommendations (2)

• Heat moisture exchangers (HMEs) are more
  effective in reducing the incidence of VAP
  compared to HHs (heated humidifiers) provided
  there are no contraindications to their use (e.g.
  patients at risk of airways obstruction)
• Where HMEs are used (except with high minute
  volume) these should not be changed routinely
  but manufacturers guidance should be followed

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A Recommendations (3)

• Non-invasive ventilation (NIV) rather than
  mechanical ventilation should be used in selected
  patients to reduce the risk of HAP
• The decisions on the method of enteral feeding to
  be used for critically ill patients should be
  made locally by each unit and on an individual
  patient basis
• Physiotherapists and respiratory therapist have a
  role in preventing respiratory complications in
  post-operative ventilated patients

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A Recommendations (4)

• Whenever clinically appropriate stress ulcer
  prophylaxis should be avoided in order to help
  preserve gastric function
• Where stress ulcer prophylaxis is indicated,
  sucralfate is to be preferred in order to reduce
  the risk of VAP
• Sucralfate should only be used in patients with
  low to moderate risk of gastro-intestinal
  bleeding

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B Recommendations (1)

• Hospital education programmes should form part of
  the risk reduction measures for HAP as part of an
  overall infection control strategy
• New ventilator circuit tubing should be provided
  for each patient
• Closed and open suctioning systems can be used
  without affecting the risk of VAP
• Measures should be taken to reduce the risk of
  aspiration to prevent VAP
• If a patient does not require supine positioning
  consideration should be given to using
  semi-recumbent positioning as a strategy to
  prevent VAP

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B Recommendations (2)

• Appropriate Legionella control of hospital water
  is required
• During building works, consideration must be
  given to addressing the risk of pulmonary
  aspergillosis. This must include
• Identifying high risk patients
• Methods to reduce all patients exposure to
  aspergillus e.g. use of floor to ceiling
  barriers, sealing of windows
• The use of HEPA filtration in high risk units
• e.g. HSCT units, ICU
• Dust reduction in clinical areas