The Clinical Management of Hospital Acquired Pneumonia. NHS Ayrshire & Arran

Transcription

1 The Clinical Management of Hospital Acquired Pneumonia Dr R G Masterton NHS Ayrshire & Arran

2 What s new in HAP/VAP? Care bundles MRSA VAP Improving outcomes with current antimicrobial New antimicrobials

3 VAP CARE BUNDLE

4 HAP Guideline Recommendations Grade Pe Preventionention Diagnosis i Treatment A B C D GPP Masterton et al. J Antimicrob Chemother. 2008;62:5-34.

5 HAP Guideline Recommendations Grade Pe Preventionention Diagnosis i Treatment A B C D GPP Masterton et al. J Antimicrob Chemother. 2008;62:5-34.

6 What is a Care Bundle? 1. Set of around 5 evidence-based interventions that apply to all patients with a common disease. 2. Ensure the delivery system means the interventions entions are delivered. ered 3. Compliance is all or nothing. 4. Measure outcomes to ascertain benefits. 5. Develop the will to deliver all the time every time. Masterton. Intensive Care Med. 2009;35:

7 The Care Bundle Approach VAP Care Bundle 5 simple, basic, universally accepted components Bed elevation Sedation vacation Daily weaning assessment Peptic ulcer prophylaxis p DVT prophylaxis Craven. Chest;2006;130:

8 VAP Care Bundle The Top Ten Empiric therapy based on knowledge of local pathogens and assessment of risk factors Immediate treatment following microbiological sampling Oral care with chlorhexadine Non invasive ventilation preferred SD for mechanically ventilated patients greater than 48 hours Assess response within 72 hours Short duration of treatment therapy - 8 days if patient on appropriate regimen and not infected by MDR pathogen Sedation vacation and weaning protocol Monotherapy in preference to combination therapy in those not at risk for pseudomonas or MDR De-escalate in responding patients once culture results available Prevention Diagnosis Treatment Rello et al. J Crit Care May 26. [Epub ahead of print] & Intensive Care Med. 2010;36:

9 VAP Care Bundle Treatment Empiric therapy based on knowledge or local pathogens and assessment of risk factors Immediate treatment following microbiological sampling Assess response within 72 hours Short duration of treatment therapy - 8 days if patient on appropriate regimen and not infected by MDR pathogen Monotherapy in preference to combination therapy in those not at risk for pseudomonas or MDR De-escalate in responding patients once culture results are available Rello et al. J Crit Care May 26. [Epub ahead of print] & Intensive Care Med. 2010;36:

10 Impact of IHI VAP Improvement Bundle VAP prevention bundle resulted in reduction of VAP rates from (P <.001) : Mean of 9.3 cases/1000 ventilator d in 2006 Mean of 23cases/ ventilator d in 2007 Mean of 2.2 cases/1000 ventilator d in 2008 Each VAP case increased: attributable hospital LoS by 10 days mean hospital cost by $40,000. Al-Tawfiq et al. Am J Infect Control Apr 17. [Epub ahead of print].

11 MRSA VAP

12 Vancomycin for MRSA Pneumonia Succes ss (%) ) Clinical Response Overall AUIC<345 AUIC>345 Moise PA, et al. Am J Health System Pharm 2000;57:S4-S9.

13 Renal toxicity & Trough Levels Nep hrotoxi icity (% %) P = < >20 MaximumVancomycin Steady State TroughConcentrations Increased Cr by 0.5 mg/dl or doubling of baseline value Jeffres MN, et al. Clin Ther 2007;29:

14 MRSA VAP Optimising vancomycin Chastre et al. IDSA 2010, Abstract 5074

15 MRSA VAP Optimising vancomycin Chastre et al. IDSA 2010, Abstract 5074 Maximum vancomycin trough levels at either Day 3, 6 or 9. Modified intention to treat cohort at end of study.

16 While there does appear to be some good evidence for the use of combination therapies involving rifampicin in the treatmentof MRSA osteomyelitisand device related infections (though patients receiving rifampicin must be closely monitoredfor hepatotoxicity and drug drug interactions), evidence supporting the use of rifampicin or other combinations in other settings is much more scant.

17 Combination Therapy Vancomycin & Rifampicin in MRSA VAP Jung YJ, et al. Crit Care Med. 2010;38:

18 NEW INTERVENTIONS

19 Tl Televancinvs. Vancomycin in HAP/VAP Difference in Success Rates TLV VAN with 95%CI Rubinstein et al. Clin Infect Dis 2010 (In press)

20 Televancin vs. Vancomycin Late Onset VAP = 4 days mechanical ventilation Pooled clinical cure rates at test of cure. Rubinstein et al. Clin Infect Dis 2010 (In press)

21 Televancin vs. Vancomycin MRSA VAP Subset Rubinstein et al. Clin Infect Dis 2010 (In press)

22 Linezolid vs Vancomycin In Nosocomial Pneumonia Chastre et al. IDSA 2010, Abstract 5074 Per protocol End of study Unknown were linezolid = 7 & vancomycin = 2. Excluded from analysis Per protocol End of treatment

23 Summary Optimising outcomes in modern VAP care means: Implementing an effective VAP Bundle Moving away from vancomycin as the staple for MRSA VAP antibiotic treatment Continuing to look for better ways of preventing and managing this condition