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Ventilator Associated Pneumonia
Arkistoidut sarjat ("Toimeton syöte" status)
When? This feed was archived on March 22, 2023 19:49 (). Last successful fetch was on February 16, 2023 22:14 ()
Why? Toimeton syöte status. Palvelimemme eivät voineet hakea voimassa olevaa podcast-syötettä tietyltä ajanjaksolta.
What now? You might be able to find a more up-to-date version using the search function. This series will no longer be checked for updates. If you believe this to be in error, please check if the publisher's feed link below is valid and contact support to request the feed be restored or if you have any other concerns about this.
Manage episode 335664732 series 2593358
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Ventilator Associated Pneumonia
Dr Swapnil Pawar
Ventilator-associated Pneumonia
Blog Written by Dr Jose Chacko
CDC definitions
Ventilator-associated event (VAE)
Ventilator-associated condition (VAC): increase in daily minimum PEEP ≥ 3 cm H2O or FiO2 ≥ 0.20 sustained for at least 2 calendar days following a baseline period (2 calendar days) of stability or improvement
Infection-related ventilator-associated complication (IVAC): Altered leukocyte count (≥ 12,000 cells/mm3 or ≤ 4000 cells/mm3) and/or temperature (> 38 °C or < 36 °C), a new antimicrobial prescription has been started and sustained for at least 4 calendar days
Possible or probable VAP: Above plus microbiological confirmation of a lower respiratory tract infection,
After the first 48 hours
Early: Days 1–4
Late: Day 5 and later
Peak: days 5–9
Incidence
The discrepancy between reports from the US and Europe (1–2.5 vs. 18.5 per 1000 ventilator days)
Differences in definition, diagnostic criteria, sampling techniques, type of intensive therapy unit (ITU), and patient population
Incidence varies depending on the underlying disorder – high in cancer, TBI, COPD, ARDS
Age does not correlate
Higher incidence in males
Outcomes
Prolongs duration of ventilation and hospitalization
Unclear whether there is attributable mortality (1% on day 30 and 1.5% on day 60)
Based on data from 58 RCTs, attributable mortality was 9%
Micro-organisms
Duration of mechanical ventilation
Length of hospital and ICU stay
Timing and cumulative exposure to antimicrobials
The local microbial ecology
Other ICU-dependent factors
Gram negative: Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, and Acinetobacter species
Late onset more likely to be MDR; it may occur with prior exposure to antibiotics
Resistance to third- and fourth generation cephalosporins in Enterobacteriaceae strains due to the expression of acquired extended-spectrum β-lactamases (ESBLs) and/ or AmpC β-lactamases is a major concern
Carbapenemase producing strains
Colistin resistance
Diagnosis
Clinical suspicion
Radiographic infiltrates
Microbiological confirmation
CPIS criteria (Pugin et al.): temperature, blood leukocytes, tracheal secretions aspect, oxygenation, radiographic infiltrates, and semi- quantitative cultures of tracheal aspirates with Gram stain
More recent: at least 2 of new onset of fever, purulent endotracheal secretions, leukocytosis or leucopenia, increase in minute ventilation, decline in oxygenation, and/or increased need for vasopressors to maintain blood pressure. However, these findings may exist in non-infective etiology
Poor sensitivity of plain chest radiographs
Biomarker generally non-beneficial
Microbiological diagnosis
Distal tracheal secretions
Gram stain has limited sensitivity and specificity
BAL vs. tracheal aspirate – overdiagnosis with tracheal aspirate alone and unnecessary antibiotic use
Meta-analysis of 5 RCTs did not show the difference in outcomes between quantitative cultures vs. non-invasive techniques
When to commence antibiotics?
General recommendation to withhold if clinically stable; however, has to be based on clinical judgment
If cultures are negative, or antibiotics are administered prior to culture, reassess after 48-72 hours whether antibiotics need to continue
Stop antibiotics based on procalcitonin levels: if the procalcitonin level is <0.5 ng/mL or has decreased more than 80% from baseline levels
Future: molecular methods – PCR. May be oversensitive
VAP prevention
Oral chlorhexidine: may be harmful
Stress ulcer prophylaxis: may be harmful
Oral and digestive decontamination: not useful in ICUs with a high level of antimicrobial resistance
Modified cuff: not useful
Routine cuff pressure monitoring: not useful
Subglottic secretion drainage: lower rates of VAP; does not shorten the time to extubation, reduce ICU length-of-stay, prevent ventilator-associated events, or reduce lower mortality rates
Head-up position: may be useful
Shorten the duration of ventilation
VAP treatment
Empirical treatment: severity of the underlying illness, risk factors for MDR pathogens, and the local resistance patterns
Septic shock at VAP onset, ARDS prior to VAP onset, acute renal replacement therapy prior to VAP
Non-immunocompromised, early-onset: third-generation cephalosporin
In other situations, initial empiric treatment should include a broad-spectrum β-lactam targeting Pseudomonas aeuroginosa and/ or ESBL-producing Enterobacteriaceae. We use betalactam – betalactamase inhibitor (Pip-taz) or carbapenem
We have a high incidence of ESBL-producing Enterobacteriaceae hence carbapenem is often used as the first line
Ceftazidime-avibactam: carbapenem-resistant Enterobacteriaceae or XDR Pseudomonas aeruginosa. Effective against extended-spectrum β-lactamase, AmpC-, Klebsiella pneumoniae carbapenemase- and OXA-48-producing Enterobacteriaceae and drug-resistant Pseudomonas aeruginosa isolates; it is not active against metallo-β-lactamase-producing strains.
MRSA cover if incidence is common
Importance of de-escalation; switch to monotherapy, reduce the duration of treatment
7 days is enough for most patients – robust evidence
Nebulized antibiotics: generally, not effective. Not effective if there is bacteremia. Repeated nebulization may prolong the duration of ventilation.
Restrict patients with VAP to XDR-Gram-negative pathogens susceptible only to colistin or aminoglycosides
XDR: non-susceptibility to at least one agent in all but two or fewer antimicrobial categories
Summary –
Awareness of VAP in ICU is important.
VAP prevention bundles should be implemented in each ICU.
Minimising the duration of mechanical ventilation and early extubation when feasible is the key to preventing VAP.
The post Ventilator Associated Pneumonia first appeared on Critical Care Education.
42 jaksoa
Arkistoidut sarjat ("Toimeton syöte" status)
When? This feed was archived on March 22, 2023 19:49 (). Last successful fetch was on February 16, 2023 22:14 ()
Why? Toimeton syöte status. Palvelimemme eivät voineet hakea voimassa olevaa podcast-syötettä tietyltä ajanjaksolta.
What now? You might be able to find a more up-to-date version using the search function. This series will no longer be checked for updates. If you believe this to be in error, please check if the publisher's feed link below is valid and contact support to request the feed be restored or if you have any other concerns about this.
Manage episode 335664732 series 2593358
- play_arrow
Ventilator Associated Pneumonia
Dr Swapnil Pawar
Ventilator-associated Pneumonia
Blog Written by Dr Jose Chacko
CDC definitions
Ventilator-associated event (VAE)
Ventilator-associated condition (VAC): increase in daily minimum PEEP ≥ 3 cm H2O or FiO2 ≥ 0.20 sustained for at least 2 calendar days following a baseline period (2 calendar days) of stability or improvement
Infection-related ventilator-associated complication (IVAC): Altered leukocyte count (≥ 12,000 cells/mm3 or ≤ 4000 cells/mm3) and/or temperature (> 38 °C or < 36 °C), a new antimicrobial prescription has been started and sustained for at least 4 calendar days
Possible or probable VAP: Above plus microbiological confirmation of a lower respiratory tract infection,
After the first 48 hours
Early: Days 1–4
Late: Day 5 and later
Peak: days 5–9
Incidence
The discrepancy between reports from the US and Europe (1–2.5 vs. 18.5 per 1000 ventilator days)
Differences in definition, diagnostic criteria, sampling techniques, type of intensive therapy unit (ITU), and patient population
Incidence varies depending on the underlying disorder – high in cancer, TBI, COPD, ARDS
Age does not correlate
Higher incidence in males
Outcomes
Prolongs duration of ventilation and hospitalization
Unclear whether there is attributable mortality (1% on day 30 and 1.5% on day 60)
Based on data from 58 RCTs, attributable mortality was 9%
Micro-organisms
Duration of mechanical ventilation
Length of hospital and ICU stay
Timing and cumulative exposure to antimicrobials
The local microbial ecology
Other ICU-dependent factors
Gram negative: Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, and Acinetobacter species
Late onset more likely to be MDR; it may occur with prior exposure to antibiotics
Resistance to third- and fourth generation cephalosporins in Enterobacteriaceae strains due to the expression of acquired extended-spectrum β-lactamases (ESBLs) and/ or AmpC β-lactamases is a major concern
Carbapenemase producing strains
Colistin resistance
Diagnosis
Clinical suspicion
Radiographic infiltrates
Microbiological confirmation
CPIS criteria (Pugin et al.): temperature, blood leukocytes, tracheal secretions aspect, oxygenation, radiographic infiltrates, and semi- quantitative cultures of tracheal aspirates with Gram stain
More recent: at least 2 of new onset of fever, purulent endotracheal secretions, leukocytosis or leucopenia, increase in minute ventilation, decline in oxygenation, and/or increased need for vasopressors to maintain blood pressure. However, these findings may exist in non-infective etiology
Poor sensitivity of plain chest radiographs
Biomarker generally non-beneficial
Microbiological diagnosis
Distal tracheal secretions
Gram stain has limited sensitivity and specificity
BAL vs. tracheal aspirate – overdiagnosis with tracheal aspirate alone and unnecessary antibiotic use
Meta-analysis of 5 RCTs did not show the difference in outcomes between quantitative cultures vs. non-invasive techniques
When to commence antibiotics?
General recommendation to withhold if clinically stable; however, has to be based on clinical judgment
If cultures are negative, or antibiotics are administered prior to culture, reassess after 48-72 hours whether antibiotics need to continue
Stop antibiotics based on procalcitonin levels: if the procalcitonin level is <0.5 ng/mL or has decreased more than 80% from baseline levels
Future: molecular methods – PCR. May be oversensitive
VAP prevention
Oral chlorhexidine: may be harmful
Stress ulcer prophylaxis: may be harmful
Oral and digestive decontamination: not useful in ICUs with a high level of antimicrobial resistance
Modified cuff: not useful
Routine cuff pressure monitoring: not useful
Subglottic secretion drainage: lower rates of VAP; does not shorten the time to extubation, reduce ICU length-of-stay, prevent ventilator-associated events, or reduce lower mortality rates
Head-up position: may be useful
Shorten the duration of ventilation
VAP treatment
Empirical treatment: severity of the underlying illness, risk factors for MDR pathogens, and the local resistance patterns
Septic shock at VAP onset, ARDS prior to VAP onset, acute renal replacement therapy prior to VAP
Non-immunocompromised, early-onset: third-generation cephalosporin
In other situations, initial empiric treatment should include a broad-spectrum β-lactam targeting Pseudomonas aeuroginosa and/ or ESBL-producing Enterobacteriaceae. We use betalactam – betalactamase inhibitor (Pip-taz) or carbapenem
We have a high incidence of ESBL-producing Enterobacteriaceae hence carbapenem is often used as the first line
Ceftazidime-avibactam: carbapenem-resistant Enterobacteriaceae or XDR Pseudomonas aeruginosa. Effective against extended-spectrum β-lactamase, AmpC-, Klebsiella pneumoniae carbapenemase- and OXA-48-producing Enterobacteriaceae and drug-resistant Pseudomonas aeruginosa isolates; it is not active against metallo-β-lactamase-producing strains.
MRSA cover if incidence is common
Importance of de-escalation; switch to monotherapy, reduce the duration of treatment
7 days is enough for most patients – robust evidence
Nebulized antibiotics: generally, not effective. Not effective if there is bacteremia. Repeated nebulization may prolong the duration of ventilation.
Restrict patients with VAP to XDR-Gram-negative pathogens susceptible only to colistin or aminoglycosides
XDR: non-susceptibility to at least one agent in all but two or fewer antimicrobial categories
Summary –
Awareness of VAP in ICU is important.
VAP prevention bundles should be implemented in each ICU.
Minimising the duration of mechanical ventilation and early extubation when feasible is the key to preventing VAP.
The post Ventilator Associated Pneumonia first appeared on Critical Care Education.
42 jaksoa
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