Ventilator

Associated
Pneumonia and
Guidelines
VAP: Definition
Pneumonia in patients receiving
invasive mechanical ventilation for at
least 48 hours
Early VAP: < 4 days in the ICU
Late VAP: > 4 days in the ICU
VAP: Incidence
Data from January 2002 June 2003
Reported as VAP rates/1000 vent days
US National Nosocomial Infection Surveillance
7.9 Cardiothoracic
9.6 Burn
9.9 Surgical
12.9 Neurosurgical
15.1 Trauma
Mean VAP Rate
(Cases/1000 vent days)
Type of ICU
VAP: Burden of Illness
Incidence 10-20% of patients receiving
mechanical ventilation > 48 hours
Increased ICU Mortality (2-4 times)
Increased ICU LOS (5-7 days)
Increased hospital costs (>$10,000 US
in additional costs)
Safdar et al, Crit Care Med, 2005; 33: 2184
VAP: Healthcare Cost
$46,000,000 Excess Cost
2
216 Excess Deaths
1
16,000 days
(55 ICU beds)
Excess Vent
days
Canada
(10.6 cases/1000 Vent days)
Burden of Illness
(per year)
1
Based on attributable mortality of 5.8%
2
Ontario cost cost methodology
Clinical Criteria for Suspicion of VAP
New or persistent infiltrate on CXR
without another cause
Plus any 2 of the following:
Purulent endotracheal secretions
Increasing oxygen requirements
Core temperature > 38.0
o
C
WBC < 3.5 or > 11.0
Adapted from N Engl J Med 2006;355:2619-30.
Host Risk Factors for VAP
Underlying pulmonary disease (e.g.
COPD)
Sepsis
ARDS
Major surgery
Multiple organ failure
Head injury (traumatic and non-
traumatic brain injury)
Ann Intern Med. 2004;141:305-13.
Other Risk Factors for VAP
Enteral nutrition
GI prophylaxis
Patient position (Head of bed
elevation)
Patient receiving paralytic agent
Reintubation
Witnessed aspiration
Ann Intern Med. 2004;141:305-13.
Ann Intern Med. 1998; 129:433-40.
Organisms and Related Prognosis
Bacteriology
S. pneumoniae
H. influenzae
MSSA
Susceptible gram
negative bacteria
Prognosis
Less severe, little
impact on outcome
Early VAP
Late VAP
Bacteriology
P. aeruginosa
Acinetobacter
MRSA
Other multiresistant
organisms
Prognosis
High attributable
morbidity and mortality
VAP Guideline Recommendations
Prevention
Diagnosis
Treatment
VAP
Guidelines:
Prevention
Ann Intern Med. 2004;141:305-13.
Subglottic Secretion Drainage
Expected endotracheal intubation
> 72 hours
Exclusion criteria:
Nasally intubated
Tracheostomy tube
Difficult endotracheal intubation
VAP Guideline
Recommendations: Prevention
Semi-recumbent positioning at 45
degree angle
Exclusion criteria:
Patient on vasopressors or undergoing resuscitation
Spine unstable or not cleared
Pelvic instability or fractures
Prone position
Intra aortic balloon pump
Unable to raise HOB because of obesity
Procedures (includes bathing)
VAP Guideline
Recommendations: Prevention
Chlorohexidine Oral Antiseptic
Exclusion criteria:
Allergy
Lack of access to patients oral cavity
VAP Guideline
Recommendations: Prevention
VAP
Guidelines:
Diagnosis
No improvement in clinical outcomes
(mortality, length of stay, antibiotic use)
compared to endotracheal aspirate
May lead to delays in initiation of
antibiotic therapy
Requires expertise, time and
personnel without added benefit
Diagnostic Bronchoscopy
NOT RECOMMENDED
Mortality of BAL vs ETA
Meta-Analysis of All trials comparing ETA with BAL
Diagnosis of suspected VAP
Endotracheal aspirates with nonquantitative
culture
Exclusion criteria:
Immunocompromised patients at physicians
discretion
VAP Guideline
Recommendations: Diagnosis
Clinical Suspicion
of VAP
New or persistent infiltrate on CXR plus 2
of the following:
Purulent endotracheal secretions
Increasing FiO2 requirements
Elevated temperature (> 38.0)
Increased WBC (>11.0) or decreased WBC
(<3.5)
Diagnosis of VAP
Endotracheal aspirate
Consider diagnostic bronchoscopy
for immunosuppressed patients
VAP Diagnosis
VAP
Guidelines:
Treatment
Treatment of VAP
Initial inadequate empiric therapy of
VAP is associated with worse
outcome
Delays in therapy associated with
worse outcome
Treatment regimens can be shortened
with similar clinical outcomes
ATS Guidelines, 2005
Meta-Analysis of All trials comparing Mono vs. Combo therapy for VAP
Mortality of Monotherapy vs
Combination Rx
Antibiotics for empiric treatment of VAP
Single effective agent for each suspected
organism
Exclusion criteria:
Patients known to be colonized or previously
infected with Pseudomonas sp. or multidrug
resistant organisms
Immunocompromised patients
VAP Guideline
Recommendations: Treatment
Choice of antibiotics for empiric
treatment of VAP
Based on local ICU resistance
patterns and patient factors
Exclusion criteria: none
VAP Guideline
Recommendations: Treatment
Discontinuation of empiric antibiotics
for VAP
If noninfectious etiology of infiltrates is
found
OR
If signs and symptoms of active infection
have resolved
Exclusion criteria: none
VAP Guideline
Recommendations: Treatment
Duration of antibiotic treatment for
confirmed VAP
Maximum of 8 days in patients in whom
initial empiric therapy was appropriate
Exclusion criteria:
Immunocompromised patients
VAP Guideline
Recommendations: Treatment
TREATMENT OF VAP
Stop empiric antibiotics for suspected VAP if another
reason for patients signs & symptoms found
Stop antibiotics for confirmed VAP after 8 days of therapy
Reassess each antibiotic daily based on culture results,
and patients signs and symptoms
Choose antibiotic on the basis of the microbiology
and resistance patterns in the ICU
Choose one effective antibiotic active against each
potential pathogen
Start empiric antibiotics at the time of clinical suspicion of VAP Empi r i c
Ther apy
Ant i bi ot i c
Sel ec t i on
Dur at i on of
Ant i bi ot i c
Ther apy
Ant i bi ot i c
Management