1. Hospital Acquired Pneumonia (HAP) By Professor Adel Khattab Prof. of Pulmonary Medicine Ain Shams University http://telemed.shams.edu.eg/moodle5

2. Definition This infection is with onset of 48-72 hours of hospitalization, development of a new or progressive infiltrate in CXR, fever, leukocytosis and purulent tracheobronchial secretions. This infection was neither present nor incubating at the time of hospitalization. This definition, however may exclude cases that occur in outpatient settings or after discharge from the hospital.

3. Definitions: HAP refers to pneumonia that occurs  48 hours after admission, which was not incubating at the time of admission. HAP is closely related & share the same principles with Ventilator-associated pneumonia (VAP) & Healthcare- associated Pneumonia (HCAP). VAP refers to pneumonia that arises more than 48–72 hours after endotracheal intubation. (American Thoracic Society, 2005)

4. Incidence of HAP 2 nd most common nosocomial infection Rate 5-15 cases/ 1000 hospital admission  6- to 20-fold in mechanically ventilated patients Increases hospital stay by 7-9 days / patient Excess cost of more than $ 40,000 / patient Mortality rate is seriously high 30- 50 % VAP most vigorous type of nosocomial pneumonia occurs 9–27% of all intubated patients Mortality rate is seriously high 30-71%

5. Importance of Hospital Acquired Infection ( HAI ) HAI are responsible for 44,000 to 98,000 deaths annually and represent a cost of $ 17 to $ 29 billion.

6. Definitions: Early-onset HAP & VAP: within the first 4 days of hospitalization. Late-onset HAP and VAP: 5 days or more of hospitalization. (American Thoracic Society, 2005)

7. Ventilator Associated Pneumonia (VAP )

8. Prevalence of VAP VAP is a common disorder, with a prevalence of 6-52 cases /100 patients depending on the population studied. Crude rate of VAP is usually 1-3% per day of intubation & mechanical ventilation. Rates are greatly higher in surgical ICU patients than in medical ICU ones.

9. Device Associated Infection Rates by Type of ICU Type of ICUVentilator Associated pneumonia * Mean Central line Associated Blood stream infection** mean Urinary catheter Associated urinary tract infection*** mean Coronary Medical Medical/surgical Neurosurgical Pediatric Surgical Burn Respiratory Trauma 10.2 8.9 11.8 18.3 5.8 14.5 24.1 6.7 17.2 5.0 6.1 4.5 5.7 8.1 4.9 14.6 4.6 7.2 7.1 8.9 5.4 8.5 5.3 10.5 7.1 8.3

10. Mortality of VAP Crude mortality rates for VAP ranges from 20- 71%, but deaths are often due to other causes in critically ill patients. A preferred measure is “ Attributable mortality”,defined as percentage of deaths that would not have occurred in the absence of infection. Attributable mortality of VAP ranges from 27- 43%

11. Host factors Medications Respiratory therapy equipment Surgery Invassive devices Gastric colonization Aspiration Numbers of bacteria virulence Bacteremia Lung Defenses Mechanical cellular/humoral Pneumonia Oropharyngeal colonization Translocation

12. Sources of infection Environment Devices Other Patients Staff Air: aspergillus Water: legionella Food:enteric Gram - ve Fomites: S. aureus RSV Air: aspergillus Water: legionella Food:enteric Gram - ve Fomites: S. aureus RSV Endotracheal tube Suction catheters Bronchoscope Respiratory therapy equipment Nasogastric tube Endotracheal tube Suction catheters Bronchoscope Respiratory therapy equipment Nasogastric tube

13. Nosocomial pneumonia(NP):risk factors for cross-transmission Increased risk for NP associated with poor hand-washing External colonization - Aerosol inoculation due to colonization of respiratory therapy equipment Nebulizers Mechanical ventilators Resuscitation bags and portable spirometers Inappropriate airway suctioning Increased risk for NP associated with poor hand-washing External colonization - Aerosol inoculation due to colonization of respiratory therapy equipment Nebulizers Mechanical ventilators Resuscitation bags and portable spirometers Inappropriate airway suctioning

14. Host factors Medications Respiratory therapy equipment Surgery Invassive devices Gastric colonization Aspiration Numbers of bacteria virulence Bacteremia Lung Defenses Mechanical cellular/humoral Pneumonia Oropharyngeal colonization Translocation ?

15. Nosocomial pneumonia: Clinical risk factors for Oropharyngeal Colonization Coma Hypotension Renal failure Leucocytosis COPD Alcoholism Coma Hypotension Renal failure Leucocytosis COPD Alcoholism Clinical underlying condition Period of hospitalization Nutritional status Antibiotic therapy Intubation ICU stay Clinical underlying condition Period of hospitalization Nutritional status Antibiotic therapy Intubation ICU stay Johanson et al, celis et al

16. Host factors Medications Respiratory therapy equipment Surgery Invassive devices Gastric colonization Aspiration Numbers of bacteria virulence Bacteremia Lung Defenses Mechanical cellular/humoral Pneumonia Oropharyngeal colonization Translocation ?

17. Nosocomial pneumonia: risk factors for gastric colonization Advanced age. Achlorhydria. Alterations in gastric juice secretion. Antacids and H2 blockers. Increased concentration of conjugated bilirubin in gastric content. Advanced age. Achlorhydria. Alterations in gastric juice secretion. Antacids and H2 blockers. Increased concentration of conjugated bilirubin in gastric content.

18. Host factors Medications Respiratory therapy equipment Surgery Invassive devices Gastric colonization Aspiration Numbers of bacteria virulence Bacteremia Lung Defenses Mechanical cellular/humoral Pneumonia Oropharyngeal colonization Translocation ?

19. Nosocomial pneumonia: risk factors for aspiration Alterations of consciousness - Trauma, sedative drugs Nasogastric intubation Supine position Endotracheal tube - Direct pass to the lower airway - Leakage around the cuff - Bacterial biofilm/dislodgement to distal airway Alterations of consciousness - Trauma, sedative drugs Nasogastric intubation Supine position Endotracheal tube - Direct pass to the lower airway - Leakage around the cuff - Bacterial biofilm/dislodgement to distal airway

20. (American Thoracic Society, 2005)

21. Microbiology of HAP Bacterial ( 80-90%): - Gram –ve bacilli (50-70%) Pseudomonas aeruginosa Enterobacteriaceae -Staphylococcus aureus (15-30%) - Anaerobic bacteria (10-30%) -Haemophilus influenzae (10-20%) -Streptococcus pneumoniae (10-20%) -Legionella speecies (4%)

22. Microbiology of HAP (con.)  Viral (10-20 %) - Cytomegalovirus - Influenza - Respiratory syncytial virus  Fungal (< 1% )

23. Bacterial pathogens associated with HAP Early-onset HAP First 4 days: Strept. pneumoniae. Hemophilus influenzae. Moraxella catarrhalis. Anaerobes (uncommon). Late-onset HAP After 4 days: Pseudomonas aeruginosa. Acinetobacter. Enterobacter sp. MRSA.

24. DIAGNOSTIC TECHNIQUES Blood, Pleural Fluid Analysis, and Culture Nonbronchoscopic evaluations: Percutaneous needle aspiration Endotracheal aspiration Blind bronchial sampling Bronchoscopic techniques: PSB BAL Tissue diagnosis Blood, Pleural Fluid Analysis, and Culture Nonbronchoscopic evaluations: Percutaneous needle aspiration Endotracheal aspiration Blind bronchial sampling Bronchoscopic techniques: PSB BAL Tissue diagnosis

25. Problems in Diagnosis of HAP Contamination by the upper airways: Solved by protecting the sampling fluid. Separation of infection from colonization: Solved by using quantitative cultures.

26. Diagnostic strategies & approaches HAP is suspected: The presence of a new or progressive radiographic infiltrate plus at least two of three clinical features (fever >38C, leukocytosis or leukopenia & purulent secretions). Lower respiratory tract sample for microscopy & culture: from all patients, ideally before antibiotic started. –Bronchoscopic or nonbronchoscopic. –endotracheal aspirate (ETA), bronchoalveolar lavage (BAL), or protected specimen brush (PSB). –Semi-quantitative or quantitative: In quantitative cultures the diagnostic threshold is ETA 10 6 cfu/ml, BAL 10 4 or 10 5 cfu/ml, PSB 10 3 cfu/ml.

27. Hospitalized patient Clinical features Suggest Infection? Order/review recent CXR Abnormal ? No further Investigations & observe Observe & investigate for other sources NO No Yes

28. Option B: Emperic treatment + Qualitative culture Adjust treatment According to Culture results or Clinical response Option A: Quantitative culture Nonbronchoscopic: EA,BAL,PSB Bronchoscopic : BAL, PSB, PBAL Treat based on results Of diagnostic testing If clinically unstable Yes

29. I will prevent disease whenever I can, prevention is preferable to cure. Modem Versoin (1964) I will prevent disease whenever I can, prevention is preferable to cure. Modem Versoin (1964)

30. Prevention of HAP (A) Regimens for specific indications: Hand washing between patient contact. Pneumococcal and influenza vaccination for population at risk. Isolating patients with highly resistant organisms such as MRSA.

31. It is not enough to produce satisfactory soap; it also necessary to induce people wash.

32. Prevention of HAP (B) Regimens used widely in some clinical settings : Nutritional support with careful attention to the route and volume of feeding. Intestinal bleeding prophylaxis, sucralfate compared with either antacids or H-2 blockers. Careful handling of ventilator tubing and associated equipments. Subglottic secretion drainage. Lateral rotation bed therapy.

33. Prevention of HAP Procedure or device Suction catheter Suction bottle Spirometry Intervention to decrease risk Single use non-sterile used for suction and change catheter between patients & after each use. Single-use disposable or wash with detergent Single-use or disposable mouthpiece & clean according to manufacture recommendations.

34. Prevention of HAP Breathing circuit Nebulizers & Humidifiers Change MV circuit every 48 hours. Periodically, drain breathing-tube condensation trap, taking care not to spill it back to patient trachea. Change & reprocess device between patients by sterilization or high level of disinfection & fill with sterile water only.

35. Classification of HAP Patients Is pneumonia mild to moderate or severe? Are specific host or therapeutic risk factors predisposing to specific pathogens present? Is pneumonia early onset (within 4 days of admission) or late onset?

36. ATS DEFINITION OF SEVERE HAP Admission of ICU Resp. failure, defined as need for mechanical ventilation or the need for > 35% oxygen to maintain an arterial oxygen saturation >90% Rapid radiographic multilobar pneumonia, or cavitation of a lung infiltrate Evidence of severe sepsis with hypotension and/or end- organ dysfunction : Shock (systolic BP 4 h Urine output <20mL/h or total urine output <80mL in 4 h(unless another explanation is available). Acute renal failure requiring dialysis Admission of ICU Resp. failure, defined as need for mechanical ventilation or the need for > 35% oxygen to maintain an arterial oxygen saturation >90% Rapid radiographic multilobar pneumonia, or cavitation of a lung infiltrate Evidence of severe sepsis with hypotension and/or end- organ dysfunction : Shock (systolic BP 4 h Urine output <20mL/h or total urine output <80mL in 4 h(unless another explanation is available). Acute renal failure requiring dialysis

37. (American Thoracic Society, 2005)

40. previously

42. Duration of Therapy: Efforts should be made to shorten the duration of therapy from the traditional 14 to 21 days to periods as short as 7 days, provided that the etiologic pathogen is not P. aeruginosa, and that the patient has a good clinical response with resolution of clinical features of Infection.

43. Control of antibiotic resistance requires aggressive implementation of several strategies : 1- Ongoing surveillance of resistance. 2- when the rate of resistance increases; using hygienic controls to limit spread of single (colonial)strains ; a-Hand hygiene (30-120 sec). b-Alcohol-based hand rubs (10-30 sec ). c-Use of disposable examination gloves during contacts with pts to decrease the problem of colonization pressure. Control of antibiotic resistance requires aggressive implementation of several strategies : 1- Ongoing surveillance of resistance. 2- when the rate of resistance increases; using hygienic controls to limit spread of single (colonial)strains ; a-Hand hygiene (30-120 sec). b-Alcohol-based hand rubs (10-30 sec ). c-Use of disposable examination gloves during contacts with pts to decrease the problem of colonization pressure.

44. 3-Hospitals should use (closed formularies) for prescription of antibiotics to limit prescribing options to one or two drugs per class. 4-Restriction of the use of antibiotics has been effective in reducing cost and excessive empiric use of broad spectrum drugs. 5-Rotational use of antibiotics (antibiotic cycling program). 3-Hospitals should use (closed formularies) for prescription of antibiotics to limit prescribing options to one or two drugs per class. 4-Restriction of the use of antibiotics has been effective in reducing cost and excessive empiric use of broad spectrum drugs. 5-Rotational use of antibiotics (antibiotic cycling program).

45. (American Thoracic Society, 2005)

46. Clinical Resolution of HAP Clinical Pulmonary Infection Score ( CPIS) TemperatureWBC countOxygenationPurulent secretionsCXR infilterates

47. Clinical Pulmonary Infection Score For every item give score : 0,1, 2. For temperature: normal 0, up to 38.5 give 1, but if higher give 2. Count the final score of all items : if 6 means clinical unresolution and unimprovement.

48. (American Thoracic Society, 2005)

49. Unresolved HAP Clinical re-assessment of the patient. Consider differential diagnosis. Exclude another site of infection ( UTI, vascular lines, bed sores, wounds…). Re-collect another samples ( ET aspirate, bronchoscopic, pleural fluid, blood…). Use multiple antibiotics instead of monotherapy. Consider steroids and open lung biopsy.

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