1. Prevention of Lower Respiratory Tract Infections

2. Learning objectives 1.Explain the relevance of pneumonia in health care institutions. 2.Outline elements for defining HAI pneumonia. 3.Identify risk factors for pneumonia. 4.Describe the measures for prevention of pneumonia. December 1, 2013 2

3. Time involved 35-40 minutes December 1, 2013 3

4. Key points Pneumonia causes morbidity and mortality and increased utilisation of resources Prevention is vital Prevention includes hand hygiene use of gloves daily assessment of weaning from a ventilator elevation of the bed head orotracheal intubation oral care with an antiseptic solution cleaning and disinfection of equipment December 1, 2013 4

5. Introduction In healthy individuals the lower respiratory tract is sterile Cough reflex, respiratory mucosa, secretions, and immunity prevent microorganisms in the LRT Impaired conditions of patients and incorrect practices contribute to healthcare-associated pneumonia December 1, 2013 5

6. The problem Pneumonia accounts for 11% - 15% of HAI and 25% of infections in ICUs Highest mortality among HAIs Postoperative pneumonia - a common complication of surgery Ventilator–associated pneumonia occurs in 8- 28% of patients Prolongs hospitalisation and antibiotic use Microorganisms often multidrug-resistant December 1, 2013 6

7. Healthcare-associated Pneumonia DEFINITION LRT infection that appears during hospitalisation in a patient who was not incubating the infection at admission December 1, 2013 7

8. Diagnosis It is diagnosed by the following: rales or bronchial breath sounds fever purulent sputum, cough, dyspnoea, tachypnea relevant radiologic changes preferably, microbiological diagnosis from bronchial lavage, transtracheal aspirate, or protected brush culture December 1, 2013 8

9. Categories* There are three pneumonia categories: PNU1 X-ray changes and clinical signs and symptoms laboratory findings PNU2 X-ray changes, clinical signs and symptoms, microbiological results PNU3 pneumonia in immuncompromised December 1, 2013 9

10. Surveillance For surveillance purposes, many practitioners use the pneumonia definition published by the U.S. Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN) December 1, 2013 10

11. Mechanical ventilation Impairs normal removal of mucus and microorganisms from the lower airway H2 blocking agents associated with colonisation of gastrointestinal tract and oropharynx December 1, 2013 11

12. Pathogenesis Microorganisms may be introduced into the LRT via contaminated equipment or staff hands December 1, 2013 12

13. Risk Factors December 1, 2013 Condition of patient Severely ill, e.g., septic shock Surgery (chest/abdomen) injuries Age Cardiopulmonary disease Cerebrovascular accidents Lung disease Coma Heavy smoker Therapy Sedation General anaesthesia Tracheal intubation Tracheostomy Enteral feeding Mechanical ventilation Broad spectrum antibiotic H2 blockers Immunosuppressive and cytotoxic drugs 13

14. Time of onset December 1, 2013 Early-onset pneumonia Four days of admission (in ICUs or after surgery) Late-onset pneumonia More than 4 days after admission 14

15. Etiological agents Early-onset pneumoniaLate-onset pneumonia Streptococcus pneumoniaePseudomonas aeruginosa Haemophilus influenzaeAcinetobacter spp. Moraxella catarrhalisEnterobacter spp. Methicillin- sensitive Staphylocoocus aureus Methicillin- resistant Staphylococcus aureus InfluenzaMultidrug - resistant organisms Respiratory syncytial or other respiratory viruses Candida spp. Aspergillus spp. December 1, 2013 15

16. Considerations Many late-onset VAPs caused by multi-resistant microorganisms In immunocompromised patients microbes: Viruses (RSV, influenza) Fungi (Candida spp. and Aspergillus) Legionella from air conditioning or water supplies Pneumocystis carinii (AIDS patients) Mycobacteria December 1, 2013 16

17. NHSN survey - causes of VAP in USA December 1, 2013 17

18. Survey in 12 European countries 2008* December 1, 2013 *European Centre for Disease Prevention and Control (ECDC) 18

19. Prevention Recommendations are designed to avoid the three mechanisms by which pneumonia develops: aspiration contamination of the aerodigestive tract contaminated equipment December 1, 2013 19

20. Prevention of postoperative pneumonia Treat lung disease prior to surgery Elevate head of the bed Avoid unnecessary suctioning Provide regular oral cavity care Encourage deep breathing and coughing Provide pain therapy (non-sedative) Use percussion and postural drainage to stimulate coughing Encourage early mobilisation December 1, 2013 20

21. Prevention of VAP - 1 Hand hygiene before and after contact with patient or respiratory secretions Gloves when handling secretions Sterile gloves for aspiration and tracheostomy care Sterile suction catheter Daily assessments of readiness to wean. Minimise the duration of ventilation and noninvasive whenever possible December 1, 2013 21

22. Prevention of VAP - 2 Elevate the head of the bed Avoid gastric over-distension Avoid unplanned extubation Orotracheal intubation Avoid H2 agents and proton pump inhibitors Regular oral care with an antiseptic solution Sterile water to rinse respiratory equipment. Remove condensate, keep the circuit closed Change ventilator circuit only when necessary December 1, 2013 22

23. Prevention of VAP - 3 Store and disinfect respiratory equipment Surveillance for VAP Direct observation of compliance Educate healthcare personnel Establish antibiotic regimens in accordance with the local situation December 1, 2013 23

24. References - 1 December 1, 2013 1.Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recom Rep 2004; 53:1-36. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr53 03a1.htm http://www.cdc.gov/mmwr/preview/mmwrhtml/rr53 03a1.htm 2.American Thoracic Society; Infectious Disease Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Amer J Respir Crit Care Med 2005; 171:388-416. http://ajrccm.atsjournals.org/ cgi/reprint/171/4/388 24

25. References - 2 December 1, 2013 1.Coffin S, Klompas M, Classen D et al. Strategies to prevent ventilator- associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol 2008; 29:S31-S40. 2.Kollef M. Prevention of hospital-associated pneumonia and ventilator– associated pneumonia. Crit Care Med 2004; 32:1396-1405. 25

26. Further reading 1.Allegranz B, Nejad SB, Combescure C, Graafmans W, Attar H, Donaldson L, Pittet P. Burden of endemic health-care-associated infection in developing countries: systematic review and meta- analysis. Lancet 2011; 377: 228 – 241. 2.Ding J-G, Qing-Feng S, Li K-C, Zheng M-H, et al. Retrospective analysis of nosocomial infections in the intensive care unit of a tertiary hospital in China during 2003 and 2007. BMC Infect Dis 2009; 9:115. December 1, 2013 26

27. Quiz 1.Most cases of hospital pneumonia are not preventable. T/F? 2.The main strategy to prevent VAP is a)Treatment of respiratory diseases b)Routine culture of patients c)Minimise duration of mechanical ventilation d)Isolation of infected patients in ICU 3.Regarding prevention of VAP, which is incorrect? a)Change circuits of mechanical ventilation only if is necessary b)Elevate head of the bed if not contraindicated c)Gloves when handling respiratory secretions d)Use of antimicrobial prophylaxis always in patients with mechanical ventilation December 1, 2013 27

28. International Federation of Infection Control IFIC’s mission is to facilitate international networking in order to improve the prevention and control of healthcare associated infections worldwide. It is an umbrella organisation of societies and associations of healthcare professionals in infection control and related fields across the globe. The goal of IFIC is to minimise the risk of infection within healthcare settings through development of a network of infection control organisations for communication, consensus building, education and sharing expertise. For more information go to http://theific.org/http://theific.org/ December 1, 2013 28