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Hospital Acquired Pneumonia

Hospital Acquired Pneumonia. Hospital Acquired Pneumonia. Pneumonia that occurs 48 hrs or more after admission, which was not incubating at the time of admission. American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416. Hospital Acquired Pneumonia. Epidemiology

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Hospital Acquired Pneumonia

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  1. Hospital Acquired Pneumonia

  2. Hospital Acquired Pneumonia • Pneumonia that occurs 48 hrs or more after admission, which was not incubating at the time of admission. American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.

  3. Hospital Acquired Pneumonia 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 American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.

  4. Hospital Acquired Pneumonia • 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 American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.

  5. What is VAP? • Pneumonia developing in a patient receiving mechanical ventilation for longer than 48–72 hours after tracheal intubation. [1] American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.

  6. 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;

  7. Ventilator Associated Pneumonia (VAP) – Key Points - • 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 American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.

  8. Hospital Acquired Pneumonia Pathogenesis

  9. Hospital Acquired Pneumonia • Pathogenesis • Invasion of the lower respiratory tract by: • Aspiration of oropharyngeal/GI organisms • Inhalation of aerosols containing bacteria • Hematogenous spread MMWR, January 3,1997/vol.46/No.RR-1

  10. Hospital Acquired Pneumonia • 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

  11. Pathogenesis MMWR, January 3,1997/vol.46/No.RR-1

  12. MRSA* Colonization Aspiration HAP

  13. Risk Factors • 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 American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.

  14. Risk Factors for MDR Pathogens Causing HAP/ VAP • 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 American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.

  15. Early Vs. Late Onset VAP • 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 American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.

  16. Preventive Strategies • 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 American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.

  17. More Preventive Strategies • 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 American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416.

  18. More Preventive Strategies • 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.

  19. Common Pathogens of VAP 25% 20% 15% 10% 5% 0% P. aeruginosa Acinetobacter spp GNEB Haemophilus S. aureus S. Pneumoniae Other Luna CM et al. Archiv Bronconeumol 2005;41: 439

  20. Pathogens of VAP in different World Areas 30% 25% 20% P. Aeruginosa Acinetobacter spp S. Maltophilia 15% Enterobacteriaceae* Haemophilus spp S. aureus 10% 5% 0% USA Latin America Europe Luna CM et al. Archiv Bronconeumol 2005;41: 439

  21. Treatment Immediate Rx. of patients with VAP Avoid the emergence of multidrug-resistant microorganisms Objective1 Objective2

  22. HAP treatment recommendations was published in 2008 for Asian Countries by Asian HAP Working Group

  23. Need for Asian HAP Guidelines • 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

  24. Need 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

  25. 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. 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). Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92

  26. Methodology 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

  27. Indian 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

  28. HAP 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

  29. Treatment Recommendations

  30. Initial 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

  31. Initial Empiric Antibiotic treatment for early onset HAP (Table I) *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

  32. Initial Empiric Antibiotic treatment for late onset HAP (Table II) *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

  33. Initial Empiric Antibiotic treatment for early onset VAP (Table III) Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92

  34. Initial Empiric Antibiotic treatment for late onset HAP (Table IV) Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92

  35. Treatment Recommendations for MDR pathogens

  36. MRSA • 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

  37. P. 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

  38. 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

  39. Antibiotic regimens against specific antibiotic – resistant pathogens Song JH and Asian HAP Working Group, Am J of Inf Control; vol 36; issue 4 May 2008; S83-S92

  40. Duration 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

  41. Role of Teicoplanin

  42. Teicoplanin in Nosocomial Pneumonia Glycopeptide antibiotics teicoplanin and Vancomycin is the First line therapy against Nosocomial Pneumonia attributable to MRSA. Hunter J D Postgrad Med J 2006; 82: 172-178

  43. Conclusions • 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

  44. Thanks for Your Attention!!

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