Preventing Nosocomial Pneumonia

Transcription

1 Prevention of Nosocomial Pneumonia Andreas F. Widmer, MD,MS,FIDSA,FSHEA Chair Infection Control University of Basel Hospitals & Clinics Basel, Switzerland Preventing Nosocomial Pneumonia Definition & Surveillance Scores & lab test General issues Chlorhexidine Keep patients off antibiotics or shorten duration Daptomycin VAP Positioning of patient SOD-SDD-Placebo Handhygiene outbreak of P.aeruginosa in ICU Environment Water in ICUs and Legionella Airborne ICU Infections

2 American Thoracic Society; Infectious Diseases Society of America [] Hospital-acquired pneumonia (HAP) Acute lower respiratory tract infection acquired after 48 hours of admission to hospital. Ventilator-associated pneumonia (VAP) Pneumonia that occurs >48 to 72 hours after endotracheal intubation. Healthcare-associated pneumonia (HCAP) Pneumonia in any patient who: Was admitted to an acute care hospital for any reason for at least 2 days, within 90 days of the infection Resided in a nursing home or long-term care facility (HCAP may be described distinctly from nursing home-acquired pneumonia [NHAP] in the future when more data are available) [2] Received recent intravenous antibiotic therapy, chemotherapy, or wound care therapy within the last 30 days of the current infection Attended a haemodialysis clinic. Klompas M.N Engl J Med 203;368;6 2

3 Developing a New, National Approach to Surveillance for VAP Figure. Ventilator-associated events surveillance definition algorithm*. *Available at: CFU = colony-forming units, FIO2 = fraction of inspired oxygen, PEEP = positive endexpiratory pressure, VAP = ventilator-associated pneumonia 2 Magill, S. Critical Care Medicine. 4(): , November 203. Magill, S. Critical Care Medicine. 4(): , November

4 Parameter Temperature, C and 36.0 Blood leukocyte level, leukocytes/mm ,000!4000 or 000 Plus band forms 500 Tracheal secretions!4+ 4+ Plus purulence Oxygenation, PaO2 :FiO2,mm Hg 240 or ARDS 240 and no ARDS Pulmonary radiograph finding No infiltrate Diffuse or patchy infiltrate Localized infiltrate Culture of tracheal aspirate specimen (semiquantitative: 0, 2, or 3+) Pathogenic bacteria cultured orno growth Pathogenic bacteria cultured + Plus same pathogenic bacteria on Gram stain + Points Clinical Pulmonary Infection Score Calculation CPIS. «At present, the CPIS has a limited role both clinically and as a research tool. Sensitivity 60% Interrater variability Kappe 0.6 Zilberberg MD,Clin Infect Dis 200; 5(S):S3 S35 4

5 Multinational, observational study of procalcitonin in ICU patients with pneumonia requiring mechanical ventilation: a multicenter observational study Bloos F.. Critical Care 20, 5:R88 ROC curves of symptoms and signs and added value CRP and procalcitonin ROC curves of symptoms and signs and added value CRP and procalcitonin (continuous results). Linear predictors for estimated risk of pneumonia: symptoms and signs=/(+exp ( breathlessness absence of runny nose diminished vesicular breathing+.404 crackles+0.96 tachycardia temperature >37.8 C)); symptoms signs and CRP=/(+exp ( breathlessness absence of runny nose diminished vesicular breathing+.404 crackles+0.96 tachycardia temperature >37.8 C+0.30 (CRP/0))); symptoms signs and PCT=/(+exp ( breathlessness absence of runny nose diminished vesicular breathing+.404 crackles+0.96 tachycardia temperature > (PCT 0))) Van Vugt SF BMJ 203;346(f2450):-2. 5

6 VAP: Introduction Ventilator-associated Pneumonia (VAP) common ICU-infection; 30-40% VAP associated with morbidity and higher mortality. Randomized controlled trials VAP prevention measurements; Although VAP No mortality SLIDE COURTESY M.BONTEN Overall attributable mortality of ventilator-associated pneumonia is 3%, with higher rates for surgical patients and patients with a mid-range severity score at admission Attributable mortality is mainly caused by prolonged exposure to the risk of dying due to increased length of ICU stay Melsen et al, Lancet Infect Dis 203; 3:

7 Rates of VAP in the US Dudeck MA American Journal of Infection Control 4 (203) Mean Rates of VAP and CRBSI Abbreviations: CRBSI, catheter-related bloodstream infection; VAP, ventilator-associated pneumonia Helmick RA et al. JAMA Surg 204;E-published Aug 27 7

8 28day survival aong 43 patients Invasive vs clinical management of VAP 8

9 Prevention of VAP Non-invasive Positive Pressure Ventilation prevents VAP development Author Patients Design no Relative Risk for VAP Brochard NEJM 95 Acute exacerbations COPD PRCT 85 0,28 (0,06-,3) Guerin Acute Respiratory Cohort Acute exacerbations COPD PRCT 64 0,3 (0,02-0,94) Acute exacerbations COPD Case match 00 0,36 (0,2-,06) Immunosuppressed pts with ARF PRCT 52 0,33 (0,07-,5) Acute Respiratory Failure Cohort 689 0,53 (0,3-0,97) Intens Care Med 98 Failure Antonelli NEJM 98 Girou JAMA 00 Hilbert NEJM 0 Carlucci AJRCCM 0 9

10 Daily interruption of sedative infusions reduces duration of mechanical ventilation Kress et al NEJM 2000; 342: 47-7 Implementation of a weaning protocol reduces duration of mechanical ventilation: A RCT ventilator management protocol (VMP) Physician directed (MD) Marelich et al. Chest 2000; 8:

11 Topical Antimicrobial Prophylaxis of the Oropharynx reduces VAP incidence,0,9 TAP-patients,8 VAP-free survival,7,6,5 Controls,4 p = ,3,2 Relative Risk Reduction VAP:, 0.62 ( ) Relative Risk Reduction ICU-mort: 0.25 ( ) 0, Time (days in study) 25 AJRCCM 200; 64: Oropharyngeal decontamination with Chlorhexidine Gluconate-2%, with or without Colistin, reduces incidence of VAP M. Koeman et al. AJRCCM 2006; 73: PLAC CHX 3 CHXCOL HR=0,352 Cum Hazard VAP 2 HR=0, Days of MV A randomized double blind, placebo-controlled, multi center study: placebo (n=30), chloorhexidine (n=27), chx+colistine (n=28).

12 Intubation and Ventilation due to. ARDS < 36hs. Mean 4±4 BL / patient with mean duration 7±3 Std. 90 day mortality 23.6% in BL vs. 4.0% supine position (P<0.00); Hazard ratio of 0.44 (95% CI, 0.29 to 0.67) N Engl J Med 203. DOI: 0.056/NEJMoa2403 2

13 Prevention nosocomial infections after Cardiac surgery Segers, P. et al. JAMA 2006;296:

14 Intubation and Ventilation due to. ARDS < 36hs. Mean 4±4 BL / patient with mean duration 7±3 Std. 90 day mortality 23.6% in BL vs. 4.0% supine position (P<0.00); Hazard ratio of 0.44 (95% CI, 0.29 to 0.67) N Engl J Med 203. DOI: 0.056/NEJMoa2403 4

15 What is Selective Decontamination of the Digestive Tract? Oropharyngeal decontamination Tobramycin, polymyxin, amphotericin B, 4dd (= Selective Oropharyngeal Decontamination) Gastrointestinal decontamination Tobramycin, polymyxin, amphotericin B, 4dd Systemic prophylaxis Cefotaxim, 4 dd gram, 4 days Avoiding antibiotics that impair colonization resistance (i.e., anti-anaerobics) Meta-analysis of the effects Systemic + Topical prophylaxis, as compared to controls, on ICU-mortality D'Amico, R. et al. BMJ 998;36:

16 Interventions SOD Oropharyngeal application 4 dd 0.5 gr. paste containing 2% polymyxin E, 2% tobramycin and 2% amphotericin B. Application of paste (4dd) around tracheostoma. Application of paste (8dd) after 2 consecutive surveillance cultures yielding yeasts. Respiratory tract (throat and sputum) surveillance cultures on admission and twice weekly. SDD Plus 4 days of cefotaxime SOD vs SDD vs Control 6

17 Interventions SDD (identical to de Jonge) SOD + Intragastric application 4 dd 0 ml of suspension containing 00 mg polymyxin E, 80 mg tobramycin and 500 mg amphotericin B (suppositoria in case of stoma). Cefotaxim 4 dd gr. i.v. during first 4 days of treatment. Nebulization of polymyxin E (4 dd 80 mg) after 2 consecutive sputum surveillance cultures with Gram negative bacteria. Nebulization of amphotericin B(4 dd 5 mg) after 2 consecutive sputum surveillance cultures with yeasts. Surveillance cultures of throat, sputum and rectum on admission and twice weekly. Use of colonization resistance impairing antibiotics was discouraged. Clinical endpoints: crude analysis ICU-mortality (%) Hospitalmortality (%) LOS in ICU (days) Mean ± SD Median LOS in hospital Mean ± SD Median Duration of mechanical ventilation Mean ± SD Median SDD N=2049 SOD N=903 Control N=989 P value 44 (2.5%) 45 (2.8%) 443 (22.3%) (32.5%) 583 (30.6%) 63 (3.7%) 3.35 ± ± ± ± ± ± (SOD vs Ctr).62± ± ±

18 Clinical endpoints: adjusted analysis Adjusted outcomes Standard Care N=990 OR SDD N=2045 OR(CI) SOD N=904 OR(CI) Mortality at day ( ) 0.86 ( ) ICU Mortality 0.8 ( ) 0.87 ( ) Hospital Mortality 0.88 ( ) 0.85 ( ) Duration of intubation.05 ( ).0 ( ) Duration of ICU-stay.06 ( ).04 ( ) Duration of hospital stay. ( ).0 ( ) Random effects logistic regression model with adjustment for age, gender, APACHE II score, ventilation, surgical/non-surgical and study center. Mean VAP Guideline existence and compliance with VAP prevention measures between countries. K Kaier BMC Infectious Diseases 204;4:99. 8

19 Mean VAP surveillance system existence and selfreported compliance with VAP prevention measures between countries. C ountry appreviatio ns : E S = SPA IN; F R = FRANC E; IT = ITALY; AT = AUSTRIA; GB = UN ITED KING D OM; DE = GER MAN Y; I N = INDI A; PT = PORTUG AL; AR = ARG ENTI NA ; BE = BEL G I U M ; CO = COLOMB I A; M X = M EXI CO; NL = N ETHERLA NDS; C H = S WITZERLAN D; AU = AUSTRA LIA; GR = GREEC E; PE = PERU; B R = BRAZIL.. K Kaier BMC Infectious Diseases 204;4:99. The initial protocol (VAP preventive bundle) included a set of () careful hand hygiene according to hospital protocol for handwashing; (2) keeping patients in a 30 semirecumbent position; (3) endotracheal cuff pressure 20 cm H2O; (4) oral care with chlorhexidine 0.2% at least 2 times a day in ventilated patients; (5) avoiding gastric overdistension and withdrawal of enteral nutrition 2 hours before nursing and patient transport to reduce the risk of aspiration; (6) avoiding programmed tracheal suction and use of closed endotracheal suctioning system when possible; (7) substitution of heat and moisture changers and ventilator circuits every 72 hours and 7 days, respectively, or when visibly soiled; and (8) daily assessment of readiness to weaning or extubation Right E. Am J Infect Control Oct 8 (204) e-e5 9

20 Mean Rates of VAP and CRBSI Abbreviations: CRBSI, catheter-related bloodstream infection; VAP, ventilator-associated pneumonia Helmick RA et al. JAMA Surg 204;E-published Aug 27 Correlation of VAP and CRBSI Rates With Self-reported Compliance Rates and Audit Rates by Year Abbreviations: CRBSI, catheter-related bloodstream infection; VAP, ventilator-associated pneumonia Helmick RA et al. JAMA Surg 204;E-published Aug 27 20

21 Correlation of VAP and CRBSI Rates With Self-reported Compliance Rates and Audit Rates by ICU Type Abbreviations: CRBSI, catheter-related bloodstream infection; VAP, ventilator-associated pneumonia Helmick RA et al. JAMA Surg 204;E-published Aug 27 Trends in VAP: Impact of a ventilator care bundle in an Italian tertiary care hospital ICU Right E. Am J Infect Control Oct 8 (204) e-e5 2

22 Prevention of nosocomial infections, with emphasis on VAP: Surveillance of VAP Non-invasive ventilation, if possible Orotracheal intubation, if possible Reduce duration of intubation sedation / weaning protocols adequate staffing levels Invasive diagnostic strategy for VAP High level of hygiene VAP-specific measures Semi-recumbent position: 00? 250? 450? Chlrhexdine oral care 22