VAP Bundle care 抗生素使用效益與臨床常見問題探討 (I)

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1 VAP Bundle care 抗生素使用效益與臨床常見問題探討 (I) 盧敏吉 中山醫學大學內科部感染科與微生物免疫科 院內感染 感染鏈的三個因素 傳染源 Reservoir Endogenous Exogenous 傳染途徑 Mode of Transmission 接觸傳染飛沫傳染空氣傳染日常用具及食物 宿主 Susceptible Host 感染管制措施 洗手! 洗手! 洗手! 隔離措施 醫療物品之消毒與滅菌 WHO 手部衛生五大策略 -Care Bundles WHO 手部衛生五大策略 -Care Bundles 抗生素管理策略 Antimicrobial Stewardship Strategies CSMH Antimicrobial Stewardship Program x MacDougall and Polk. Clin Microb Rev, 2005, 18:638 Education for antibiotic use Guidelines/pathways Formulary restriction and preauthorization Audit & feedback De escalation therapy dose optimization Employment of IT for education, audit,. Periodic review and feedback of antimicrobial uses 1

2 Carbapenem-resistant Acinetobacter bumannii Vancomycin-resistant Enterococcus Nosocomial Infection Density by ICU Types in Hospitals, 2010 (TNIS) A bundle is 是一個以有計劃的方式, 來改進醫療照護過程, 並能改善病人的預後 是施行一個包含 3 至 5 套小且直接的臨床步驟 集中 (collectively) 可靠 (reliably ) 持續 (continuously) /WhatIsaBundle.htm Bundle Care: Background 1 st Care Bundle 是 Dr. Peter Pronovost 所發展的 ( ) The insertion and management of CVC s In ICUs of hospitals in Michigan Developed a checklist of key interventions for insertion and management of CVC s recommended by the CDC 2002 guidelines were every time a CVC was inserted to ensure implement 2

3 Keystone ICU Project: The Results 66% reduction in Central Line Bloodstream Infections (CLBSI) Interventions: Hand hygiene Max. barrier prec. during insertion CHG antiseptic on insertion site Avoid femoral CLs Remove CL when not needed Pronovost P, et al. NEJM 2006;355: Rate Per 1,000 CL Days 格式 : 16 Risk Factors for Nosocomial Pneumonia A number of US institutions are now reporting zero VAP rates Dudeck MA, Horan TC, Peterson KD, et al. National Healthcare Safety Network (NHSN) Report, data summary for 2010, device associated module. Am J Infect Control 2011; 39: This NHSH data collection reports the rate of ventilator associated pneumonia from a sample of healthcare facilities in the United States. VAP is difficult to prevent; 2 groups of risk factors: Instrumentation of the airway with an endotracheal tube and subsequent microaspirations) patient related factors (e.g. preexisting pulmonary disease) not amenable to prevention Major risk factor = mechanical intubation Factors that enhance colonization of the oropharynx &/or stomach: Administration of antibiotics Admission to ICU Underlying chronic lung disease Conditions favoring aspiration into the respiratory tract or reflux from GI tract: Supine position *GERD NGT placement *Coma/delirium Intubation and self-extubation Immobilization Surgery of head/neck/thorax/upper abdomen 3

4 Risk Factors for Nosocomial Pneumonia (cont d) Difficulty of VAP Diagnosis Conditions requiring prolonged use of mechanical ventilatory support with potential exposure to contaminated respiratory devices &/or contact with contaminated hands Host Factors: Extremes of age Malnutrition Immunocompromised Underlying condition/disease process Cook D et al, Ann Intern Med 1998;129: Unreliability of clinical diagnosis Purulent secretion DDx of fever/leukocytosis CXR: New & persistent pulmonary infiltrates Overdiagnosis of VAP Tracheal colonization with pathogenic bacteria in patients with ET tubes Multiple alternative causes of radiographic infiltrates in mechanically ventilated patients High frequency of other sources of fever in critically ill patients Primary Route of Bacterial Entry into Lower Respiratory Tract Micro or macro aspiration of oropharyngeal pathogens Leakage of secretions containing bacteria the ET cuff Ventilator-Associated Pneumonia Risk factor Intubation Reintubation Nasotracheal intubation Supine body position Pharmacological paralysis Daily change of ventilator circuits Preventive measure Non-invasive ventilation Avoiding reintubation by noninvasive ventilation Prefer oral intubation Semi-recumbent body position Avoid muscle relaxants Change of ventilator circuit no more than once per week Ewig et al., Thorax 2002;57;366 Semi-recumbent at o Ventilator-Associated Pneumonia Independent Risk Factors Hazard rate for VAP during the stay in ICU Continuous Removal of Subglottic Secretions Variables Relative OR Gastric aspiration 5.1 Reintubation more than once 5.0 COPD 1.9 PEEP 1.7 MV duration > 3 days 1.2 Höffken and Niederman. Chest 2002;122:2183 Cook, D. J. et. al. Ann Intern Med 1998;129:

5 Impact on patient outcomes vs. on VAP rates alone? VAP incidence by most interventions may be flawed because of the absence of a gold standard for VAP diagnosis a reduction in MV, in LOS, or in antibiotic consumption Ventilator associated Pneumonia VAP Care Bundle Evaluation of the head of the bed to between Daily sedative interruption and daily assessment of readiness to extubate Peptic ulcer disease prophylaxis Deep venous thrombosis prophylaxis if not contraindicated Crookshanks H. et al 2008 Impact on patient outcomes vs. on VAP rates alone? VAP incidence by most interventions may be flawed because of the absence of a gold standard for VAP diagnosis a reduction in MV, in LOS, or in antibiotic consumption Daily assessment of readiness to wean & Daily sedative interruption Ventilator LOS reduction LOS reduction X VAP rate VAP Prevention Early tracheostomy X short term mortality X long term mortality X VAP incidence Tracheostomy timing X MV duration X sedation X ICU LOS X hospital LOS X more complications PREVENTING ENDOTRACHEAL TUBE COLONIZATION AND MINIMIZING CONTAMINED MICROASPIRATIONS Prevention of biofilm formation: silver-coated endotracheal tubes Endotracheal tube with drainage of subglottic secretions Device for continuous control of endotracheal tube cuff pressure (Pcuff) Elevation of the head of the bed MODULATION OF COLONIZATION Oral decontamination with antiseptics Selective digestive and oral decontamination Probiotics Educational programs and bundles of care 5

6 Silver coated ETT Reduced rate (1/3) of microbilogical confirmed VAP Delayed occurrence of VAP X intubation duration X ICU LOS X hospital LOS X mortality VAP Reduction with ET Suction Above the Cuff Smulders et al. Chest;121: Subglottic drainage VAP prevention (RR=0.55) Reduced ICU LOS Decreased MV duration Increased time to 1 st episode of VAP Pcuff cm H 2 O X VAP rate X ICU mortality X hospital mortality X ICU LOS X hospital LOS HOB Elevation Torres et al, Annals of Int Med 1992;116: Ibanez et al. JPEN 1992;16: Orozco-Levi et al. Am J Respir Crit Care Med 1995;152: Drakulovic et al. Lancet 1999;354: Davis et al. Crit Care 2001;5:81-87 Grap et al. Am J of Crit Care : HOB at 30 45º 35 6

7 HOB Elevation Leads to Significant Deduction in VAP Is HOB Elevation Done? Despite effectiveness of HOB elevation, compliance is poor. Degrees of HOB Elevation Grap et al. Am J Crit Care 1999;8: Grap et al. Am J Crit Care 2005;14: Dravulovic et al. Lancet 1999;354: VAP Prevention PREVENTING ENDOTRACHEAL TUBE COLONIZATION AND MINIMIZING CONTAMINED MICROASPIRATIONS Prevention of biofilm formation: silver-coated endotracheal tubes Endotracheal tube with drainage of subglottic secretions Device for continuous control of endotracheal tube cuff pressure (Pcuff) Elevation of the head of the bed MODULATION OF COLONIZATION Oral decontamination with antiseptics Selective digestive and oral decontamination Probiotics Educational programs and bundles of care Fig 2 Forest plot showing effect of oral decontamination prophylaxis compared with no prophylaxis on risk of ventilator associated pneumonia. Chan E Y et al. BMJ 2007;334:889 Fig 3 Forest plot showing effect of oral decontamination prophylaxis compared with no prophylaxis on overall mortality. SELECTIVE DIGESTIVE DECONTAMINATION The specialist Advisers state that there was concern about Clostridium difficile and the risk of increasing antibiotic resistance through the use of antibiotics in SDD. They point out that few of the studies have been undertaken in the UK. In particular, many of the trials were carried out in countries with low risk of MRSA Chan E Y et al. BMJ 2007;334:889 7

8 VAP bundle care: Implementation The first challenge is to decide which preventive measures should be included in a bundle; there is no consensus and many investigators have developed their own set of interventions VAP bundle care: Implementation The first challenge is to decide which preventive measures should be included in a bundle; there is no consensus and many investigators have developed their own set of interventions VAP bundle care: Implementation The second challenge is to find the most efficient way to implement a bundle approach How to implement Very little information available on this issue Dependent on the culture of the organisation The following ideas may help 1.Find a colleague who is interested also! 2.Find out all the info on the subject you can 3.Liase with other colleagues in other organisations for good ideas 4.Leader nominate/high visibility 5.Buy in staff/other disciplines 6.Education 7.Communication channels 8.Time implement/wont get it perfect 9. Review current policy/guidelines 10.MOTIVATION AND ENERGY Standards of Care Healthcare workers are committed to delivering high standards of care to all patients Standards of care are generally defined by evidence based guidelines, e.g. infection control guidelines: IDSA guidelines (USA) CDC guidelines (USA) IDST guidelines (Taiwan) 8

9 Summary A Care bundle is a simple tool used to improve reliability in care delivery Elements must be evidence based Can be used for different conditions or treatments and adapted locally Thank you for your attention! 9