Lâcher les VAP pour les VAC, les IVAC?...(CDC) INTRODUCTION

Transcription

1 Lâcher les VAP pour les VAC, les IVAC?...(CDC) INTRODUCTION VAP surveillance is needed to measure incidence and to gauge the success of prevention efforts. However, VAP diagnosis is a complex issue for ICU physicians. Therefore, the CDC developed a new approach to VAP surveillance in order to make the surveillance more objective. The result is an algorithm for diagnosing Ventilator-Associated Events (VAEs) rather than VAP. VAES are based on objective conditions, i.e. ventilator settings. 1

2 CONVENTIONAL DEFINITION: CDC Radiology Two or more serial chest radiographs with at least 1 of the following: 1. New or progressive and persistent infiltrate 2. Consolidation 3. Cavitation Systemic signs (at least 1) 1. Fever (>38 C or >100.4 F) 2. Leukopenia (<4000 WBC/mm3) or leukocytosis ( WBC/mm3) 3. For adults 70 years old, altered mental status with no other recognized cause Pulmonary signs (at least 2) 1. New onset of purulent sputum, or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements 2. Worsening gas exchange (eg, desaturations, increased oxygen requirements, or increased ventilator demand) 3. New onset or worsening cough, or dyspnea, or tachypnea 4. Rales or bronchial breath sounds 100 Diagnosing VAP sensitivity AUC = 0.98 AUC = 0.5 AUC 1. Histologogy: Bronchoscopy + Q cult Blind sample + Q cult Clinical scores (CPIS) Surveillance data specificity 100 Bonten MJM, ICPIC Geneva

3 Commentary American Journal of Infection Control 2011 Eight initiatives that misleadingly lower ventilator-associated pneumonia rates Michael Klompas Interpret clinical signs as strictly as possible Interpret chest radiographs as strictly as possible Require consensus between 2 or more infection preventionists Seek endorsement of intensivists before «certifying» suspected cases of VAP Require BAL for diagnosis Set quantitative growth thresholds for endotracheal aspirate and BAL cultures Transfer patients who require prolonged mechanical ventilation Expand surveillance to include uncomplicated postoperative patients REVIEW C O URRENT PINION Is a ventilator-associated pneumonia rate of zero really possible? Michael Klompas

4 INTRODUCTION VAP surveillance is needed to measure incidence and to gauge the success of prevention efforts. However, VAP diagnosis is a complex issue for ICU physicians. Therefore, the CDC developed a new approach to VAP surveillance in order to make the surveillance more objective. The result is an algorithm for diagnosing Ventilator-Associated Events (VAEs) rather than VAP. VAEs are based on objective conditions, i.e. ventilator settings. Developing a new, national approach to surveillance for ventilator-associated events: executive summary. Magill SS, Klompas M, Balk R, Burns SM, Deutschman CS, Diekema D, Fridkin S, Greene L, Guh A, Gutterman D, Hammer B, Henderson D, Hess DR, Hill NS, Horan T, Kollef M, Levy M, Septimus E, Vanantwerpen C, Wright D, Lipsett P. Organization American Association of Critical-Care Nurses American Association for Respiratory Care American College of Chest Physicians American Thoracic Society Association of Professionals in Infection Control and Epidemiology Council of State and Territorial Epidemiologists Healthcare Infection Control Practices Advisory Committee Surveillance Working Group Infectious Diseases Society of America Society for Healthcare Epidemiology of America Society of Critical Care Medicine U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion National Institutes of Health Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion Representative(s) Suzanne Burns and Beth Hammer Dean Hess Robert Balk and David Gutterman Nicholas Hill and Mitchell Levy Linda Greene Carole VanAntwerpen Daniel Diekema Edward Septimus Michael Klompas Clifford Deutschman, Marin Kollef, and Pamela Lipsett Don Wright David Henderson Scott Fridkin, Alice Guh, Shelley Magill, Teresa Horan, others 4

5 13/12/2013 National Healthcare Safety Network (NHSH) - CDC Surveillance for Ventilator-associated Events in Adults (VAC and IVAC) A NEW ANTIMICROBIAL AGENT IS STARTED AND CONTINUED FOR DAYS INTUBATION SIRS STABILITY OR IMPROVEMENT on the ventilator WORSENING OXYGENATION 2 days 2 days Worsening is defined by one of the following: - Minimum daily FiO2 value increases 2 0 points - Minimum daily PEEP level increases 3 cmh20 5

6 REVIEW C O URRENT PINION Ventilator-associated events surveillance: a patient safety opportunity Michael Klompas 2013 MAJOR ARTICLE Rapid and Reproducible Surveillance for Ventilator-Associated Pneumonia Michael Klompas, Ken Kleinman, Yosef Khan, R. Scott Evans James, F. Lloyd, Kurt Stevenson, Matthew Samore, Richard Platt, for the CDC Prevention Epicenters Program 2011 Date Ventilator day Maximum PEEP Maximum FiO2 Maximum temperature Maximum WBC Minimum WBC Sputum or BAL Specimen Gram stains neutrophils Jan Jan Jan Jan Jan Jan Jan Jan Sputum Moderate* Jan Jan Jan Jan Jan Jan Jan

7 MAJOR ARTICLE Rapid and Reproducible Surveillance for Ventilator-Associated Pneumonia Michael Klompas, Ken Kleinman, Yosef Khan, R. Scott Evans James, F. Lloyd, Kurt Stevenson, Matthew Samore, Richard Platt, for the CDC Prevention Epicenters Program 2011 Crude Outcomes of Patients With and Whithout VAP According to Conventional Versus Streamlined Definitions Conventional definition Streamlined definition VAP positive (n = 57) VAP negative (n = 542) P VAP positive (n = 30) VAP negative (n = 569) P Mechanical ventilation days, median (IQR) 18 (11-27) 7 (4-12) < (11-22) 7 (4-12) < Intensive care days, median (IQR) 19 (14-31) 10 (6-17) < (13-37) 10 (6-18) < Hospital days, median (IQR) 26 (21-34) 18 (11-28) < (19-36) 18 (12-29) Hospital mortality 13 (23%) 128 (24%) (23%) 134 (24%) Developing a new, national approach to surveillance for ventilator-associated events: executive summary. Magill SS, Klompas M, Balk R, Burns SM, Deutschman CS, Diekema D, Fridkin S, Greene L, Guh A, Gutterman D, Hammer B, Henderson D, Hess DR, Hill NS, Horan T, Kollef M, Levy M, Septimus E, Vanantwerpen C, Wright D, Lipsett P. 7

8 13/12/2013 Developing a new, national approach to surveillance for ventilator-associated events: executive summary. Magill SS, Klompas M, Balk R, Burns SM, Deutschman CS, Diekema D, Fridkin S, Greene L, Guh A, Gutterman D, Hammer B, Henderson D, Hess DR, Hill NS, Horan T, Kollef M, Levy M, Septimus E, Vanantwerpen C, Wright D, Lipsett P. Developing a new, national approach to surveillance for ventilator-associated events: executive summary. Magill SS, Klompas M, Balk R, Burns SM, Deutschman CS, Diekema D, Fridkin S, Greene L, Guh A, Gutterman D, Hammer B, Henderson D, Hess DR, Hill NS, Horan T, Kollef M, Levy M, Septimus E, Vanantwerpen C, Wright D, Lipsett P. 8

9 ADVANTAGES AND DISAVANTAGES ++++ On one hand, that definition focused on events might circumvent subjectivity and inaccuracy of the definition of VAP (facilitate electronic assessment, make interfacility comparisons more meaningful, and encourage broader prevention strategies) On the other hand, embedding VAP in the larger concept of VAEs may dilute the attention to VAP prevention. REVIEW C O URRENT PINION Ventilator-associated events surveillance: a patient safety opportunity Michael Klompas 2013 VAC incidence Hayashi n = UCI 28% Prospero n= ICU Muscedere n = ICUs 15% 10,5% 9

10 Our objectives were to assess: OBJECTIVES (1) the current incidence of VAEs, (2) the causes related to the first episode of VAEs, i.e.; nosocomial infections (including VAP), iatrogenic adverse events (IAEs) and interventions (transport and fluid resuscitation), (3) the reality of a correlation between VAEs and VAPs episodes, (4) the impact of VAEs on antibiotic consumption and length on mechanical ventilation. 10

11 METHODS Material Longitudinal prospective French multicenter Outcomerea database (22 units) Patients were classified as to the presence of at least one VAC or VAC-SIRS or IVAC episode during their first session of mechanical ventilation (from intubation to the first successful extubation). Inclusion criteria 18 years Mechanical ventilation for 5 days Exclusion criteria More than 40% of missing data METHODS Definitions VAC was defined as first 2 days of stable or decreasing level of PEEP range ( 6, 10 and 16 mmhg) and a stable or improved PaO 2 /FiO 2 ratio followed by a rise in PEEP range 2 days or a decreasing PaO2/FiO2 ratio 2 days by more than 50 mmhg with the same level of PEEP or by more than 100 mmhg whatever the level of PEEP. A NEW ANTIMICROBIAL AGENT IS STARTED AND CONTINUED FOR 4 DAYS SIRS INTUBATION OXYGENATION STABILITY OR IMPROVEMENT 2 days WORSENING OXYGENATION 2 days

12 METHODS VAP diagnostic required - clinical suspicion (a persistent pulmonary infiltrates on chest radiographs combined with purulent tracheal secretions, and/or equal to 36.5 C, and/or peripheral blood leukocyte countgreater thanorequalto10x10 9/ Lorlessthanorequalto4x10 9 /L) - a quantitative microbiological confirmation (proximal or distal samples) (protected specimen brush ( 10 3 CFU/mL), plugged telescopic catheter specimen ( 10 3 CFU/mL), bronchoalveolar lavage fluid specimen ( 10 4 CFU/mL), or endotracheal aspirate(( 10 5 (CFU/mL) RESULTS (1) 13,702 patients in the database (120,316 ICU-days) 6,277 patients with at least one day on MV 3,028 patients with at least 5 consecutive days on MV 51,117 ventilator-days 2,331 patients (77%) 1,107 (47.5%) with only one episode 524 (22.5%) with 2 episodes 274 (11.8%) with 3 episodes 426 (18.3%) with 4 episodes with at least one episode of VAC 12

13 RESULTS (2) 2,117 patients (70%) with at least one episode of VAC-SIRS 1,145 (38%) NO NEW ANTIBIOTIC from D-2 to D (32%) NEW ANTIBIOTIC TREATMENT from D-2 to day for < 4 days (3%) 869 for 4 days (29%) IVAC (or ICU discharge, death, withholding or withdrawing lifesustaining medical treatment) RESULTS (3): Number of etiologies per patient for the first episodes Number of etiologies per patient VAC VAC-SIRS IVAC n = 2331 n 2117 n = (n, %) 818 (35.1) 714 (33.7) 189 (21.8) 1 (n, %) 726 (31.2) 659 (31.1) 260 (29.9) 2 (n, %) 445 (19.1) 413 (19.5) 213 (24.5) 3 (n, %) 214 (9.2) 210 (9.9) 124 (14.3) 4 (n, %) 128 (5.5) 121 (5.7) 83 (9.6) 13

14 RESULTS (4): ETIOLOGIES Variables a VAC n = 2331 VAC-SIRS n 2117 IVAC n = 869 Nosocomial infections 637 (27.3) 617 (29.1) 381 (43.8) Pneumonia 339 (14.5) 329 (15.5) 240 (27.6) Tracheobronchitis 23 (1) 21 (1) 12 (1.4) Bloodstream infection 173 (7.4) 168 (7.9) 95 (10.9) Catheter-related infection 81 (3.5) 76 (3.6) 44 (5.1) Urinary infection 102 ( (4.4) 42 (4.8) Sinusitis 5 (0.2) 5 (0.2) 4 (0.5) Viral infection 10 (0.4) 10 (0.5) 8 (0.9) Surgical site infections 41 (1.8) 44 (2.1) 30 (3.5) Iatrogenic adverse events 322 (13.8) 302 (14.3) 137 (15.8) Pneumothorax 37 (1.6) 34 (1.6) 23 (2.6) Failure of planned extubation 11 (0.5) 9 (0.4) 1 (0.1) Accidental extubation 21 (0.9) 22 (1) 9 (1) Self-extubation 71 (3) 60 (2.8) 19 (2.2) Venous puncture accident 14 (0.6) 13 (0.6) 9 (1) Atelectasis 52 (2.2) 52 (2.5) 20 (2.3) Peripheral thrombosis 36 (1.5) 34 (1.6) 18 (2.1) Pulmonary embolism 9 (0.4) 7 (0.3) 1 (0.1) Myocardial infarction 10 (0.4) 11 (0.5) 4 (0.5) Cardiac arrest 43 (1.8) 43 (2) 24 (2.8) Cardioversion 29 (1.2) 29 (1.4) 17 (2) Gastrointestinal bleeding 26 (1.1) 26 (1.2) 11 (1.3) Acute mesenteric ischemia 5 (0.2) 5 (0.2) 4 (0.5) Intestinal pseudo-obstruction 2 (0.1) 2 (0.1) 0 Transport 387 (16.6) 355 (16.8) 186 (21.4) Fluid resuscitation 123 (5.3) 113 (5.3) 58 (6.7) a Expressed as number (percentage) RESULTS (5) Cumulative incidence rates Daily incidence rate (% [95% CI]) Day 5 Day 10 Day 15 Day 20 Day 28 VAP 10.7 [9.7 ; 11.9] 17.0 [15.7 ; 18.4] 19.1 [17.7 ; 20.5] 20.7 [19.3 ; 22.2] 21.7 [20.3 ; 23.2] VAC 68.1 [66.4 ; 69.8] 75.1 [73.6 ; 76.7] 76.7 [75.1 ; 78.1] 76.8 [75.4 ; 78.4] 77.0 [75.5 ; 78.5] 14

15 RESULTS (6): CORRELATION BEETWENN VAP AND VAC OCCURENCES per center per year R-square = 0.67 (p<0.0001) Number of VAC Number of VAP RESULTS (5): Specificity and sensitivity of VAP with VAC, VAC-SIRS and IVAC Variable Sensitivity Specificity Positive predictive value Negative predictive value VAC 0.92 ( ) 0.28 ( ) 0.32 ( ) 0.90 ( ) VAC-SIRS 0.89 ( ) 0.37 ( ) 0.35 ( ) 0.90 ( ) IVAC 0.67 ( ) 0.75 ( ) 0.50 ( ) 0.86 ( ) 15

16 RESULTS: OUTCOMES Number of days alive without antibiotics at day 28 for patients with and without VAEs Number of days without antibiotics at day 28, median [Q1; Q3] a P< 0.05 vs no VAE No VAE VAC VAC-SIRS IVAC (n = 697) (n = 2331) (n = 2117) (n = 869) 24 [2;26] 17 [4; 23] a 16 [3;23] a 10 [1; 19] a Number of days alive without mechanical ventilation at day 28 for patients with and without VAEs Number of days without mechanical ventilation at day 28, median [Q1; Q3] a P< 0.05 vs no VAE No VAE VAC VAC-SIRS IVAC (n = 697) (n = 2331) (n = 2117) (n = 869) 24 [0;26] 14 [0; 23] a 12 [0;22] a 5 [0; 18] a ONE DAY POINT PREVALENCE STUDY: design (all patients under MV 48 hours at 8 A.M on the study day) DAILY SCREENING A NEW ANTIMICROBIAL AGENT IS STARTED AND CONTINUED FOR 4 DAYS SIRS INTUBATION OXYGENATION STABILITY OR IMPROVEMENT 2 days A.M ON STUDY DAY WORSENING OXYGENATION 2 days 16

17 MONTH INCIDENCE STUDY: design (all consecutive patients under MV) INTUBATION No criteria for stability or improvement for 2 calendar days A NEW ANTIMICROBIAL AGENT IS STARTED OXYGENATION STABILITY OR IMPROVEMENT 2 days SIRS WORSENING OXYGENATION 2 days AND CONTINUED FOR 4 DAYS DAILY SCREENING 28 days CONCLUSIONS VAEs are common and associated with a high morbidity. VAEs rate seems to be a good indicator for quality-improvement purpose rather than a replacement for VAP surveillance (good negative predictive value; low positive predictive value). However, given that VAEs are related to many different causes, prevention strategies are not easy to design. 17