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Pneumonia in the Critical Care Setting

Pneumonia in the Critical Care Setting. Laura Loftis, M.D., M.S. Associate Professor of Pediatrics and Medical Ethics Baylor College of Medicine. Objectives. 1. To review diagnostic criteria for pneumonia 2. To examine treatment algorithms for pneumonia

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Pneumonia in the Critical Care Setting

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  1. Pneumonia in the Critical Care Setting Laura Loftis, M.D., M.S. Associate Professor of Pediatrics and Medical Ethics Baylor College of Medicine

  2. Objectives 1. To review diagnostic criteria for pneumonia 2. To examine treatment algorithms for pneumonia 3. Upon completion, the learner will be able to identify controversies surrounding identification of ventilator associated pneumonia

  3. Categories of pneumonia 1. Community acquired pneumonia 2. Pneumonia in special populations • immunocompromised • cystic fibrosis • chronically ventilator dependent 3. Ventilator associated pneumonia (VAP) Ventilator associated condition X

  4. Categories of pneumonia 1. Community acquired pneumonia 2. Pneumonia in special populations • immunocompromised • cystic fibrosis • chronically ventilator dependent 3. Ventilator associated pneumonia (VAP)

  5. Guideline Eligibility Criteria: • Age ≥ 60 days to 17 years • Healthy children without underlying conditions • Clinical findings of CAP • Guideline Exclusion Criteria: • Aspiration • Recent hospitalization (< 7 days before the onset of illness) • Evidence-Based Outcomes Center Team: • Quinn Franklin, MS, CCLS, Research Specialist • Jennifer Nichols, MPH, Research Specialist • Charles Macias, MD, MPH, Director

  6. Clinical Indicators • May be subtle • Fever • Young infants may have afebrile pneumonia related to Chlamydia trachomatis • may be the only sign of occult pneumonia in highly febrile young children • Tachypnea • absence of tachypnea - single most valuable sign for excluding pneumonia • Respiratory distress • Retractions, hypoxemia (< 90% sats on RA), irritability, nasal flaring • Grunting, when present, is a sign of severe disease and impending respiratory failure • Cough • may be minimal if primarily an alveolar process Ann Emerg Med. 1999;33(2):166; JAMA 1998;279(4):308

  7. Clinical Indicators - Lung exam • Crackles or rales • Diminished breath sounds • Wheezes • more common in atypical or viral • Pleural effusion - chest pain with splinting, dullness to percussion, distant breath sounds, pleural friction rub

  8. Academic Emergency Medicine, 1996: 3(5), 396

  9. Radiographic patterns • Segmental consolidation - reasonably specific for bacterial pneumonia but lacks sensitivity • not always easy to distinguish from segmental collapse (atelectasis), which is apparent in about 25 percent of children with bronchiolitis • In a study of 254 children with radiographically defined pneumonia, the etiology was determined in 215 • The sensitivity and specificity of alveolar infiltrate for bacterial pneumonia were 72 and 51 percent, respectively • the sensitivity and specificity of interstitial infiltrates for viral pneumonia were 49 and 72 percent, respectively Acta Paediatr. 1993;82(4):360; Pediatr Radiol. 1974;2(3):155.; J Paediatr Child Health. 1990;26(4):209; Pediatrics 1998;102(6):1369; Thorax. 2002;57(5):438; Thorax. 1981;36(6):469

  10. Alveolar – note airbronchograms Interstitial

  11. Atelectasis Lobar consolidation

  12. Pleural effusions

  13. RADIOLOGIC EVALUATION • Not necessary to confirm the diagnosis of suspected CAP • in children with mild, uncomplicated lower respiratory tract infection who are well enough to be treated as outpatients • Radiographic findings are poor indicators of the etiologic diagnosis • Radiographic findings may lag behind the clinical findings • For hospitalized children • to assess for the presence of effusions or other complications

  14. Admission Criteria: • Unable to tolerate oral fluids and medications; severely dehydrated • Moderate or severe respiratory distress • Failed outpatient antibiotic treatment • Altered mental status • Oxygen saturation consistently < 90% • Unsafe to send home / poor follow-up

  15. CAP Pathogens • S pneumoniae • Most common bacteria in all age groups • less commonly S aureus or group A strep • "Atypical" bacterial pneumonia • Mycoplasma pneumoniae or Chlamydophila (formerly Chlamydia) pneumoniae • Preschool aged children had as many episodes of atypical bacterial LRIs as older children. • Afebrile pneumonia of infancy • generally seen between two weeks and four months of life. • classically caused by C. trachomatis, Clinical Infectious Diseases 2011: 53(7), e25-e76

  16. Pediatrics, 2004:113(4), 701-707.

  17. Pleural Effusion • small, simple pleural effusions • ampicillin to cover S. pneumoniae. • ill-appearing children or those with clinical deterioration • vancomycin and cefotaxime. • complicated pleural effusion • Chest thoracostomy tube (with or without fibrinolytics) or VATS

  18. Categories of pneumonia 1. Community acquired pneumonia 2. Pneumonia in special populations • immunocompromised • cystic fibrosis • chronically ventilator dependent 3. Ventilator associated pneumonia (VAP)

  19. Immunocompromised pt • humoral immune deficiencies with accompanying diminished opsonizing capacity • functional asplenia, hematopoietic malignancy, transplantation, or immunoglobulin deficiency • encapsulated bacteria Streptococcus pneumoniae • decreased cell-mediated immunity or macrophage function • in patients receiving T-lymphocyte depleting therapies for rheumatologic diseases or inflammatory bowel disease. • intracellular organisms (eg, Mycobacteria, Legionella, Nocardia, Strongyloides) • infection due to yeasts (eg, Histoplasma, Cryptococcus) or molds (eg, Aspergillus) • neutrophil dysfunction* / neutropenia / receiving glucocorticoids and/or T-cell suppression** • chronic granulomatous disease* • organ transplant recipients who require long-term immune suppression ** • Nocardia and nontuberculous mycobacteria

  20. Immunocompromised pt • Sequential infection • Ex: viral infection preceding bacterial or fungal infection • Multiple simultaneous infections • Ex: dual infection with Pneumocystis jirovecii (formerly P. carinii) and cytomegalovirus • Disseminated disease (CNS, bones, abdomen) • Ex: Aspergillus species, mycobacterial, or Nocardia infections • Superimposition of another process (lung injury or drug toxicity) N Engl J Med. 1998;338(24):1741 ; http://www.uptodate.com/contents/pulmonary-infections-in-immunocompromised-patients?source=search_result&search=pneumonia+in+immunocompromised&selectedTitle=2%7E150

  21. So… • Vanc (at meningitic doses), cefotaxime, zosyn …to start • ID consult • Early imaging (CT / MRI) and specific microbiologic diagnoses are essential • Invasive procedures (biopsies and bronchoscopy) are often necessary • advanced diagnostic testing including immunohistology and quantitative molecular assays • Reduction of immune suppression may be as important as antimicrobial therapy in the ultimate success of treatment N Engl J Med. 1998;338(24):1741 ; http://www.uptodate.com/contents/pulmonary-infections-in-immunocompromised-patients?source=search_result&search=pneumonia+in+immunocompromised&selectedTitle=2%7E150

  22. Categories of pneumonia 1. Community acquired pneumonia 2. Pneumonia in special populations • immunocompromised • cystic fibrosis • chronically ventilator dependent 3. Ventilator associated pneumonia (VAP)

  23. Simon RH. Cystic fibrosis: Antibiotic therapy for lung disease. UpToDate http://www.uptodate.com/contents/cystic-fibrosis-antibiotic-therapy-for-lung-disease?source=search_result&search=cystic+fibrosis+and+pneumonia&selectedTitle=1%7E150

  24. Cystic Fibrosis • current culture recommendations • perform cultures every three months • although the value of antibiotic susceptibility testing based on conventional in vitro cultures has been questioned • the correlation between test results and clinical response is poor Am J Infect Control. 2003;31(3 Suppl):S1.; J Pediatr. 2009;155(6 Suppl):S73.

  25. Cystic Fibrosis The persistence of bacteria despite aggressive treatment is thought to be due to: • Poor penetration of antibiotics into purulent airway secretions • Native or acquired antibiotic resistance • CF-related defects in mucosal defenses • Biofilms produced by the bacteria that may render antibiotics ineffective or interfere with host defenses Simon RH. Cystic fibrosis: Antibiotic therapy for lung disease. UpToDate http://www.uptodate.com/contents/cystic-fibrosis-antibiotic-therapy-for-lung-disease?source=search_result&search=cystic+fibrosis+and+pneumonia&selectedTitle=1%7E150

  26. Clinical indicators to treat? • Increased cough • Increased sputum production or chest congestion • Decreased exercise tolerance or increased dyspnea with exertion • Increased fatigue • Decreased appetite • Increased respiratory rate or dyspnea at rest • Change in sputum appearance • Fever (present in a minority of patients) • Absenteeism from school or work • Increased nasal congestion or drainage J Pediatr. 2001;139(3):359.

  27. Treatment considerations • Pseudomonas aeruginosa  • Chronic infection - an independent risk factor for accelerated loss of pulmonary function and decreased survival • Conversion of P. aeruginosa to the mucoid phenotype worsens prognosis • Burkholderia cepacia complex  • Chronic infection - associated with an accelerated decline in pulmonary function and shortened survival in CF • Lung transplantation is associated with recurrent and often severe infection, • Lung transplantation associated with poor outcomes, particularly for those carrying B. cenocepacia • is considered to be a contraindication to transplantation in many centers Pediatr Pulmonol. 2001;32(5):356; Pediatr Pulmonol. 2002;34(2):91; Paediatr Respir Rev. 2002;3(3):230; J Clin Microbiol. 2004;42(12):5537; Am J Respir Crit Care Med. 2006;173(4):421

  28. Treatment considerations • treat any S. aureus • treat Achromobacter xylosoxidans • Some isolates can be particularly inflammatory and are associated with rates of FEV1 deterioration • uncertainty regarding the importance of treating Stenotrophomonas maltophilia (S. maltophilia) • merely a marker of more severe lung disease or a cause of it? • Aspergillus species are generally not treated • appear to be an unlikely cause of pulmonary exacerbations Simon RH. Cystic fibrosis: Antibiotic therapy for lung disease. UpToDate http://www.uptodate.com/contents/cystic-fibrosis-antibiotic-therapy-for-lung-disease?source=search_result&search=cystic+fibrosis+and+pneumonia&selectedTitle=1%7E150

  29. Treatment considerations • When in vitro testing can identify no antibiotic to which a bacterium is susceptible, select a combination of antibiotics that would otherwise be chosen empirically for that pathogen. • generally avoid using two beta lactam antibiotics simultaneously • based upon in vitro studies showing the antimicrobial effect of adding the second beta lactam is unpredictable and can sometimes be antagonistic to the first • continue administering oral azithromycin during the acute exacerbation if it is a component of the chronic pulmonary regimen. Simon RH. Cystic fibrosis: Antibiotic therapy for lung disease. UpToDate http://www.uptodate.com/contents/cystic-fibrosis-antibiotic-therapy-for-lung-disease?source=search_result&search=cystic+fibrosis+and+pneumonia&selectedTitle=1%7E150

  30. Simon RH. Cystic fibrosis: Antibiotic therapy for lung disease. UpToDate http://www.uptodate.com/contents/cystic-fibrosis-antibiotic-therapy-for-lung-disease?source=search_result&search=cystic+fibrosis+and+pneumonia&selectedTitle=1%7E150

  31. Antibiotic synergy testing • The only large clinical trial that studied the effect of combination antibiotic susceptibility testing • failed to demonstrate any benefit associated with this approach • Meta analysis: Combination antibiotic susceptibility testing • did not improve clinical or bacteriologic outcomes • did not prolong the period until the next acute exacerbation Lancet. 2005;366(9484):463; Cochrane Database Syst Rev. 2008

  32. Categories of pneumonia 1. Community acquired pneumonia 2. Pneumonia in special populations • immunocompromised • cystic fibrosis • chronically ventilator dependent 3. Ventilator associated pneumonia (VAP)

  33. Ventilator-dependent children • tracheostomy tubes bypass the protection of the nose, mouth, and upper airway • the tube may result in various degrees of ulceration and tracheal denudation • a humidified circuit results in colonization of the trachea • aspirates show an average of six isolates per specimen, and the mean bacterial concentration was 107 organisms / ml • In 1976: • most frequent aerobic isolates - S. pneumoniae and S. aureus. • predominant anaerobes - gram-positive cocci, F. nucleatum, and B. fragilis. • replacement of one pathogen by another occurs frequently • In 2010: • gram-negative rods accounted for 71% of microorganisms Ann Otol Rhinol Laryngol, 74 (1965), pp. 785–798; Chest, 85 (1984), pp. 39–44; Chest, 76 (1979), pp. 420–424 ; Chest, 74 (1978), pp. 635–639

  34. Ventilator-dependent children • Tracheitis v tracheobronchitis v pneumonia? • colonization v real infection? • culture material via tracheal aspirate suction trap, BAL, blind protected telescoping catheter (miniBAL)? • quantitative cultures, semi-quantitative? • No correlation found between the concentrations of polymorphonuclear leukocytes and quantitative bacterial counts Chest, 74 (1978), pp. 635–639; CHEST 1979: 76: 420-424; CHEST 2013; 144(1):32–38; Pediatr Pulmonol. 2012; 47:409–414; Ped Crit Care Med. 2008 Jan;9(1):96-100;

  35. Ventilator-dependent children • following trach placement 40% readmitted within 12 months • 45% pneumonia / tracheitis • clinical indicators • oxygen saturations declined • secretions changed in color, viscosity, or odor • Increased need for airway suctioning • Increased need for oxygen supplementation or ventilatory support • new infiltrates or opacities on chest radiographs • evidence-based guidelines lacking • treat based on prior cultures or current gram stain Chest, 74 (1978), pp. 635–639; CHEST 1979: 76: 420-424; CHEST 2013; 144(1):32–38; Pediatr Pulmonol. 2012; 47:409–414; Ped Crit Care Med. 2008 Jan;9(1):96-100; Semin Pediatr Infect Dis 2006:17:11.

  36. Categories of pneumonia 1. Community acquired pneumonia 2. Pneumonia in special populations • immunocompromised • cystic fibrosis • chronically ventilator dependent 3. Ventilator associated pneumonia (VAP) Ventilator associated condition X

  37. Ventilator Associated Pneumonia (VAP) • The second most common hospital associated infection • Accounts for 20% nosocomial infections in PICU’s • Increased morbidity for patients • Increased length of stay in the hospital • Increased cost • trach /vent dependent kids sig more likely to develop a VAT CHEST 2013; 144(1):32–38

  38. VAP • clinical criteria for VAP are subjective and nonspecific: • worsening oxygenation • change in the quality or quantity of sputum production • new or progressive infiltrates • from our AQI project - On 4 consecutive days, 4 different radiologists read the films and used 4 different words/phrases to describe the same thing • autopsy series reveal that 1/3 to ½ of patients who met clinical criteria for VAP did not have pneumonia. • CDC working group - shift the focus of surveillance from pneumonia alone to complications of mechanical ventilation in general. The Joint Commission Journal on Quality and Patient Safety 2008: 34(11) 629.

  39. NEJM 2013:368;16

  40. VAC – new definitions • do not include radiographic criteria • reflects the recognition that they are counterproductive in surveillance definitions • because they introduce substantial complexity and subjectivity without increasing accuracy • opportunity to identify a population of patients who have serious complications that have previously not been acknowledged or attended to by quality-improvement programs • will enable hospitals to benchmark their rates against peer institutions in a more meaningful way • Antibiotic stewardship - the inclusion of an antibiotic criterion in the definition of IVAC will provide hospitals with a routine, widely reportable benchmark for the prescribing of antibiotics in their ICUs

  41. VAC in pediatrics • Of 645 mechanically ventilated patients admitted, 22 (3.4%) met criteria for VAC - incidence 0.829%, lower than the 2.3% to 11.5% reported in adult studies • Patients with VAC experienced - • a significantly longer mean length of stay in the PICU (27.6 22.043 days vs 6.61 7.27 days; P 5 .000) • and higher mean total ventilator time (519.31 457.60 h vs 95.60 138.83 h; P 5 .000). • significant association between tracheostomy and VAC ( P < .000) and between chronic ventilator dependence and VAC ( P < .002). • cultured microorganisms: Gram-negative rods 71%; staphylococcal or streptococcal species 26% • Of those with two or more potentially causative pathogens - 67% (n=4) were in patients with a tracheostomy CHEST 2013; 144(1):32–38

  42. Prevention • bundled care!

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