Guidelines 2017 for the management of hospitalacquired pneumonia (HAP) and. ventilator-associated. pneumonia (VAP)

Transcription

1 Guidelines 2017 for the management of hospitalacquired pneumonia (HAP) and ventilator-associated Modifiez le style des sous-titres du masque pneumonia (VAP) Filip Moerman Présentation pour les soins int printemps 2018

2 Abbreviations HAP = hospital-acquired pneumonia = nosoc pn VAP = ventilator-associated pneumonia HCAP = health-care assoc pneumonia: def: CAP = community-acquired pnumonia (shorter is better) ERS/ESICM/ESCMID/ALAT Based on the organisations guidelines. Ref: Torres, et al. Eur Respir J 2017

3 Scope & Purpose Risk factors on MDR infection include mech vent > 7d (OR6); prior AB use (OR13,5) Worldwide rise of MDR pathogens resulting in crude mortality (up to 70% for HAP!) These guidelines don t apply for neither HIV+ pts nor drug-induced immunosuppression RCT s + Observ studies + Syst reviews Classical four-level evidence (high, moderate, low, very low) recomm: strong or weak.

4 In intubated patients suspected of having VAP, should distal samples be obtained or proximal samples? Recomm: DISTAL samples of the LOWER respir tract (weak recomm, low evid)

5 Discussion Obtain these samples PRIOR to AB-treatment, because samples lose Se and Spe Goal: to narrow the initial empiric AB choice Endotrach aspir (non-invasive): over-identification of bacteria by direct examination. In CRITICALLY ILL pts, benefits of invasive techniques are less clear (esp septic shock, ARDS), because of iatrogeic morbidity ( gas exchange) Cost-effect studies Ɇ, but Ǝ AB-resist future cost

6 Narrow or large spectrum AB choice for patients with nosoc pn (HAP & VAP) with early onset (in the absence of known MDR)? Late onset infection large spectrum Recomm: narrow (weak recomm, very low evid)

7 Discussion (I) Early onset < 4d of hospitalisation No RCTs exist that compare the effectiveness of broad- and narrow-sp AB in empiric use in this case. Avoids resistance Several studies show % of MDR in early-onset as low as 10% (max 50%) However, C3* more likely to cause C. difficile * No Cefipime (Maxipime ) is mentioned POSSIBLE EXCEPTIONS: septic shock, P. aeroginosa, known ESBL, chronic heart disease, severe COPD, alcohol abuse, DM, steroid use.

8 Discussion (II) Choice equally depends on the local frequency of MDR-pathogens in the ICU in question Glycopeptides and aminosides: more drug related toxicities (kidney) Future hope on (more) PCR-D/ with high sensitivity, always keeping in mind colonisation vs active/invasive infection

9 Chicken meat: more harmful than you may think (Campylo with GB, ESBL, )

10 In «high-risk» (S shock, former AB-use, MDR colon., ) VAP or HAP, should it be bitherapy or monotherapy for empiric use? Recomm: combination therapy (gram-neg / MRSA) (strong recomm, moderate evid)

11 Discussion Patient at high risk of MDR / imminent mortality Single gram-neg cover +/- MRSA cover In case of septic shock, consider adding antipseudomonal

12 In summery

13 Cfr IDSA guidelines

14 Must we continue combination Rx? Few RCTs have assessed this problem Combination Rx for the entire treatment duration, only and maybe advantageous in preventing resistant strain emergence enhance treatment efficacy But CAVE higher nephrotoxicity! In MOST situations Rx can be safely switched to monotherapy after 3-5 days, ONLY if microbiology confirms ongoing treatment efficacy and favourable clinical evolution.

15 What if CPE (CRE) appears? Coli PLUS tige/genta Be aware that CPE without ESBL exists No cost-effectiveness studies exist; this equally counts for the initial combination treatment regimens, which apparently differ a lot inbetween ICU units worldwide.

16 In patients with HAP/VAP, can duration of AB be reduced safely to 7-10 days (instead of 14)? Recomm: 7-8 days (weak recomm, moderate evid)

17 Discussion (I) 7 to 8 days under following conditions: good clinical response to therapy, no cystic fibrosis, no lung abcess, no necrotizing pneumonia, no empyema**. No indication at all for routine AB for >3 days «if low probability of HAP and clinically ok», i.e. low clinical pulm inf score (CPIS). There exist two systemic reviews (6 RCTs!) on mixed early and late onset VAP: with regard to 28day mortality: no difference! And no differences in relapse rate between 7 and 14d**.

18 Discussion (II) Potential benefit of short term AB with regard to resistance selection and side-effects, as well as cost. Former evidence confirms that longer AB courses are required in following circumstances: MRSA pneumonia, necrotising pneumonia / empyema, concomitant endocarditis.

19 Evaluating progress during treatment for VAP/HAP: via bedside clinical asessment or rather serial biomarkers? Recomm: bedside clinical assessment represents good clinical practice according to the panel

20 Discussion (I) What clinical evaluation means: tracheobronchial secretion volume, temperature, X-ray evolvement, PaO2/FiO2, WBC-count Situation should improve within 48hrs after ABstart. CRP / PCT score rather well on evaluation but no RCTs assessing this, exist. «you don t treat a CRP» On CRP: 3 observ studies exist: CRP 3x/week. Good and poor responders (resp CRP ratios < 0,67 and non-response or biphasic). Mortality rate 53% in the poor and 20% in the good response group (p=0,01)

21 Discussion (II) On PCT: levels were significantly higher at days 3 and 7 in nonsurvivors than in survivors. PCT at day 3 = the strongest predictor of mortality (observ design!!) PCT remains expensive. Don t forget (several studies pointed this out): age is a risk factor, as well as renal impairment

22 In patients on treatment for HAP/VAP, can PCT be used to shorten treatment duration? Recomm : no (strong recomm, moderate evid)

23 Discussion (I) Routine measurement of serum PCT is not recommended when the anticipated duration is 7-8 days. In other words, never treat shorter than one week! However, according to the panel, «PCT levels together with clinical assessment are sometimes indicated with the aim of changing treatment duration». This entails good clinical practice. Which clinical circumstances: see table:

24 Table

25 Discussion (II) In patients with severely compromised immunity, typically treated with longer courses of AB, discontinuation of treatment based on PCT may result in cost savings and less selection of resistance. In these cases CRP is less good as a parameter for evolution since CRP may be persistantly elevated due to noninfectious inflammatory disorders. One Cost-Eff-study exists(canada, 2007: Pontet et al): 6 days of routine PCT measurement costs outweigh 2 days reduction in AB duration.

26 Short topics Oral decontamination with chlorhexidine Selective oropharyngeal decontamination Selective digestive decontamination Emergence of resistance with SOD and SDD

27 Oral decontamination

28 Effectiveness of Chlorhexidine oral decontamination

29 Sel orophar decont: marked reduction in the incidence of VAP, but not on mortality

30 Selective digestive decontamination

31 Effect of selective decontamination on antimicrobial resistance in intensive care units: a systematic review and meta-analysis. Lancet Infect Dis Daneman N, et al. No association with a significant difference in the prevalence of colonisation or infection with ESBL, CPE, MRSA or VRE

32 And what about travelling?