Presentation on theme: "Objectives 1. To review diagnostic criteria for pneumonia"— Presentation transcript:
0 Pneumonia in the Critical Care Setting Laura Loftis, M.D., M.S.Associate Professor of Pediatrics and Medical EthicsBaylor College of MedicineTextxxx00.#####.ppt 4/15/2017 3:37:49 AM
1 Objectives 1. To review diagnostic criteria for pneumonia 2. To examine treatment algorithms for pneumonia3. Upon completion, the learner will be able to identify controversies surrounding identification of ventilator associated pneumoniaTextxxx00.#####.ppt 4/15/2017 3:37:49 AM
2 Categories of pneumonia 1. Community acquired pneumonia2. Pneumonia in special populationsimmunocompromisedcystic fibrosischronically ventilator dependent3. Ventilator associated pneumonia (VAP)Ventilator associated conditionTextXxxx00.#####.ppt 4/15/2017 3:37:49 AM
3 Categories of pneumonia 1. Community acquired pneumonia2. Pneumonia in special populationsimmunocompromisedcystic fibrosischronically ventilator dependent3. Ventilator associated pneumonia (VAP)Textxxx00.#####.ppt 4/15/2017 3:37:49 AM
4 Guideline Eligibility Criteria: Age ≥ 60 days to 17 years Healthy children without underlying conditionsClinical findings of CAPGuideline Exclusion Criteria:AspirationRecent hospitalization (< 7 days before the onset of illness)Evidence-Based Outcomes Center Team:Quinn Franklin, MS, CCLS, Research SpecialistJennifer Nichols, MPH, Research SpecialistCharles Macias, MD, MPH, DirectorTextxxx00.#####.ppt 4/15/2017 3:37:49 AM
6 Clinical Indicators May be subtle Fever Young infants may have afebrile pneumonia related to Chlamydia trachomatismay be the only sign of occult pneumonia in highly febrile young childrenTachypneaabsence of tachypnea - single most valuable sign for excluding pneumoniaRespiratory distressRetractions, hypoxemia (< 90% sats on RA), irritability, nasal flaringGrunting, when present, is a sign of severe disease and impending respiratory failureCoughmay be minimal if primarily an alveolar processIn one report, 26 percent of 146 children (<5 years) with fever ≥39ºC, no clinical evidence of pneumonia or other localizing signs, and peripheral white blood cell count ≥20,000/microL had radiographic evidence of pneumoniaAnn Emerg Med. 1999;33(2):166; JAMA 1998;279(4):308xxx00.#####.ppt 4/15/2017
7 Clinical Indicators - Lung exam Crackles or ralesDiminished breath soundsWheezesmore common in atypical or viralPleural effusion - chest pain with splinting, dullness to percussion, distant breath sounds, pleural friction rub
9 Radiographic patterns Segmental consolidation - reasonably specific for bacterial pneumonia but lacks sensitivitynot always easy to distinguish from segmental collapse (atelectasis), which is apparent in about 25 percent of children with bronchiolitisIn a study of 254 children with radiographically defined pneumonia, the etiology was determined in 215The sensitivity and specificity of alveolar infiltrate for bacterial pneumonia were 72 and 51 percent, respectivelythe sensitivity and specificity of interstitial infiltrates for viral pneumonia were 49 and 72 percent, respectivelyActa Paediatr. 1993;82(4):360; Pediatr Radiol. 1974;2(3):155.; J Paediatr Child Health. 1990;26(4):209; Pediatrics 1998;102(6):1369; Thorax. 2002;57(5):438; Thorax. 1981;36(6):469
13 RADIOLOGIC EVALUATION Not necessary to confirm the diagnosis of suspected CAPin children with mild, uncomplicated lower respiratory tract infection who are well enough to be treated as outpatientsRadiographic findings are poor indicators of the etiologic diagnosisRadiographic findings may lag behind the clinical findingsFor hospitalized childrento assess for the presence of effusions or other complications
14 Admission Criteria:Unable to tolerate oral fluids and medications; severely dehydratedModerate or severe respiratory distressFailed outpatient antibiotic treatmentAltered mental statusOxygen saturation consistently < 90%Unsafe to send home / poor follow-up
16 CAP Pathogens S pneumoniae Most common bacteria in all age groups less commonly S aureus or group A strep"Atypical" bacterial pneumoniaMycoplasma pneumoniae or Chlamydophila (formerly Chlamydia) pneumoniaePreschool aged children had as many episodes of atypical bacterial LRIs as older children.Afebrile pneumonia of infancygenerally seen between two weeks and four months of life.classically caused by C. trachomatis,Clinical Infectious Diseases 2011: 53(7), e25-e76
21 Pleural Effusion small, simple pleural effusions ampicillin to cover S. pneumoniae.ill-appearing children or those with clinical deteriorationvancomycin and cefotaxime.complicated pleural effusionChest thoracostomy tube (with or without fibrinolytics) or VATS
22 Categories of pneumonia 1. Community acquired pneumonia2. Pneumonia in special populationsimmunocompromisedcystic fibrosischronically ventilator dependent3. Ventilator associated pneumonia (VAP)Textxxx00.#####.ppt 4/15/2017 3:37:49 AM
23 Immunocompromised pthumoral immune deficiencies with accompanying diminished opsonizing capacityfunctional asplenia, hematopoietic malignancy, transplantation, or immunoglobulin deficiencyencapsulated bacteria Streptococcus pneumoniaedecreased cell-mediated immunity or macrophage functionin patients receiving T-lymphocyte depleting therapies for rheumatologic diseases or inflammatory bowel disease.intracellular organisms (eg, Mycobacteria, Legionella, Nocardia, Strongyloides)infection due to yeasts (eg, Histoplasma, Cryptococcus) or molds (eg, Aspergillus)neutrophil dysfunction* / neutropenia / receiving glucocorticoids and/or T-cell suppression**chronic granulomatous disease*organ transplant recipients who require long-term immune suppression **Nocardia and nontuberculous mycobacteria
24 Immunocompromised pt Sequential infection Ex: viral infection preceding bacterial or fungal infectionMultiple simultaneous infectionsEx: dual infection with Pneumocystis jirovecii (formerly P. carinii) and cytomegalovirusDisseminated disease (CNS, bones, abdomen)Ex: Aspergillus species, mycobacterial, or Nocardia infectionsSuperimposition of another process (lung injury or drug toxicity)N Engl J Med. 1998;338(24):1741 ;
25 So… Vanc (at meningitic doses), cefotaxime, zosyn …to start ID consult Early imaging (CT / MRI) and specific microbiologic diagnoses are essentialInvasive procedures (biopsies and bronchoscopy) are often necessaryadvanced diagnostic testing including immunohistology and quantitative molecular assaysReduction of immune suppression may be as important as antimicrobial therapy in the ultimate success of treatmentN Engl J Med. 1998;338(24):1741 ;
26 Categories of pneumonia 1. Community acquired pneumonia2. Pneumonia in special populationsimmunocompromisedcystic fibrosischronically ventilator dependent3. Ventilator associated pneumonia (VAP)Textxxx00.#####.ppt 4/15/2017 3:37:49 AM
27 Simon RH. Cystic fibrosis: Antibiotic therapy for lung disease Simon RH. Cystic fibrosis: Antibiotic therapy for lung disease. UpToDate
28 Cystic Fibrosis current culture recommendations perform cultures every three monthsalthough the value of antibiotic susceptibility testing based on conventional in vitro cultures has been questionedthe correlation between test results and clinical response is poorAm J Infect Control. 2003;31(3 Suppl):S1.; J Pediatr. 2009;155(6 Suppl):S73.
29 Cystic FibrosisThe persistence of bacteria despite aggressive treatment is thought to be due to:Poor penetration of antibiotics into purulent airway secretionsNative or acquired antibiotic resistanceCF-related defects in mucosal defensesBiofilms produced by the bacteria that may render antibiotics ineffective or interfere with host defensesSimon RH. Cystic fibrosis: Antibiotic therapy for lung disease. UpToDate
30 Clinical indicators to treat? Increased coughIncreased sputum production or chest congestionDecreased exercise tolerance or increased dyspnea with exertionIncreased fatigueDecreased appetiteIncreased respiratory rate or dyspnea at restChange in sputum appearanceFever (present in a minority of patients)Absenteeism from school or workIncreased nasal congestion or drainageJ Pediatr. 2001;139(3):359.
31 Treatment considerations Pseudomonas aeruginosa Chronic infection - an independent risk factor for accelerated loss of pulmonary function and decreased survivalConversion of P. aeruginosa to the mucoid phenotype worsens prognosisBurkholderia cepacia complex Chronic infection - associated with an accelerated decline in pulmonary function and shortened survival in CFLung transplantation is associated with recurrent and often severe infection,Lung transplantation associated with poor outcomes, particularly for those carrying B. cenocepaciais considered to be a contraindication to transplantation in many centersPediatr Pulmonol. 2001;32(5):356; Pediatr Pulmonol. 2002;34(2):91; Paediatr Respir Rev. 2002;3(3):230; J Clin Microbiol. 2004;42(12):5537; Am J Respir Crit Care Med. 2006;173(4):421
32 Treatment considerations treat any S. aureustreat Achromobacter xylosoxidansSome isolates can be particularly inflammatory and are associated with rates of FEV1 deteriorationuncertainty regarding the importance of treating Stenotrophomonas maltophilia (S. maltophilia)merely a marker of more severe lung disease or a cause of it?Aspergillus species are generally not treatedappear to be an unlikely cause of pulmonary exacerbationsSimon RH. Cystic fibrosis: Antibiotic therapy for lung disease. UpToDate
33 Treatment considerations When in vitro testing can identify no antibiotic to which a bacterium is susceptible, select a combination of antibiotics that would otherwise be chosen empirically for that pathogen.generally avoid using two beta lactam antibiotics simultaneouslybased upon in vitro studies showing the antimicrobial effect of adding the second beta lactam is unpredictable and can sometimes be antagonistic to the firstcontinue administering oral azithromycin during the acute exacerbation if it is a component of the chronic pulmonary regimen.Simon RH. Cystic fibrosis: Antibiotic therapy for lung disease. UpToDate
34 Simon RH. Cystic fibrosis: Antibiotic therapy for lung disease Simon RH. Cystic fibrosis: Antibiotic therapy for lung disease. UpToDate
35 Antibiotic synergy testing The only large clinical trial that studied the effect of combination antibiotic susceptibility testingfailed to demonstrate any benefit associated with this approachMeta analysis: Combination antibiotic susceptibility testingdid not improve clinical or bacteriologic outcomesdid not prolong the period until the next acute exacerbationThe reason to bring this up.. It is difficult to arrange (goes to Canada) and requires quite a bit of time for the isolates to grow (so not a quick turn around). Not saying not to do it at all but when asked by a distraught parent this info could assuage some concernsLancet. 2005;366(9484):463; Cochrane Database Syst Rev. 2008xxx00.#####.ppt 4/15/2017
36 Categories of pneumonia 1. Community acquired pneumonia2. Pneumonia in special populationsimmunocompromisedcystic fibrosischronically ventilator dependent3. Ventilator associated pneumonia (VAP)Textxxx00.#####.ppt 4/15/2017 3:37:49 AM
37 Ventilator-dependent children tracheostomy tubes bypass the protection of the nose, mouth, and upper airwaythe tube may result in various degrees of ulceration and tracheal denudationa humidified circuit results in colonization of the tracheaaspirates show an average of six isolates per specimen, and the mean bacterial concentration was 107 organisms / mlIn 1976:most frequent aerobic isolates - S. pneumoniae and S. aureus.predominant anaerobes - gram-positive cocci, F. nucleatum, and B. fragilis.replacement of one pathogen by another occurs frequentlyIn 2010:gram-negative rods accounted for 71% of microorganismsAnn Otol Rhinol Laryngol, 74 (1965), pp. 785–798; Chest, 85 (1984), pp. 39–44; Chest, 76 (1979), pp. 420–424 ; Chest, 74 (1978), pp. 635–639
38 Ventilator-dependent children Tracheitis v tracheobronchitis v pneumonia?colonization v real infection?culture material via tracheal aspirate suction trap, BAL, blind protected telescoping catheter (miniBAL)?quantitative cultures, semi-quantitative?No correlation found between the concentrations of polymorphonuclear leukocytes and quantitative bacterial countsChest, 74 (1978), pp. 635–639; CHEST 1979: 76: ; CHEST 2013; 144(1):32–38; Pediatr Pulmonol. 2012; 47:409–414; Ped Crit Care Med Jan;9(1):96-100;
39 Ventilator-dependent children following trach placement 40% readmitted within 12 months45% pneumonia / tracheitisclinical indicatorsoxygen saturations declinedsecretions changed in color, viscosity, or odorIncreased need for airway suctioningIncreased need for oxygen supplementation or ventilatory supportnew infiltrates or opacities on chest radiographsevidence-based guidelines lackingtreat based on prior cultures or current gram stainChest, 74 (1978), pp. 635–639; CHEST 1979: 76: ; CHEST 2013; 144(1):32–38; Pediatr Pulmonol. 2012; 47:409–414; Ped Crit Care Med Jan;9(1):96-100; Semin Pediatr Infect Dis 2006:17:11.
40 Categories of pneumonia 1. Community acquired pneumonia2. Pneumonia in special populationsimmunocompromisedcystic fibrosischronically ventilator dependent3. Ventilator associated pneumonia (VAP)Ventilator associated conditionTextXxxx00.#####.ppt 4/15/2017 3:37:49 AM
41 Ventilator Associated Pneumonia (VAP) The second most common hospital associated infectionAccounts for 20% nosocomial infections in PICU’sIncreased morbidity for patientsIncreased length of stay in the hospitalIncreased costtrach /vent dependent kids sig more likely to develop a VATTextCHEST 2013; 144(1):32–38xxx00.#####.ppt 4/15/2017 3:37:49 AM
42 VAP clinical criteria for VAP are subjective and nonspecific: worsening oxygenationchange in the quality or quantity of sputum productionnew or progressive infiltratesfrom our AQI project - On 4 consecutive days, 4 different radiologists read the films and used 4 different words/phrases to describe the same thingautopsy series reveal that 1/3 to ½ of patients who met clinical criteria for VAP did not have pneumonia.CDC working group - shift the focus of surveillance from pneumonia alone to complications of mechanical ventilation in general.TextThe Joint Commission Journal on Quality and Patient Safety 2008: 34(11) 629.xxx00.#####.ppt 4/15/2017 3:37:49 AM
43 TextNEJM 2013:368;16xxx00.#####.ppt 4/15/2017 3:37:49 AM
44 VAC – new definitions do not include radiographic criteria reflects the recognition that they are counterproductive in surveillance definitionsbecause they introduce substantial complexity and subjectivity without increasing accuracyopportunity to identify a population of patients who have serious complications that have previously not been acknowledged or attended to by quality-improvement programswill enable hospitals to benchmark their rates against peer institutions in a more meaningful wayAntibiotic stewardship - the inclusion of an antibiotic criterion in the definition of IVAC will provide hospitals with a routine, widely reportable benchmark for the prescribing of antibiotics in their ICUsTextxxx00.#####.ppt 4/15/2017 3:37:49 AM
45 VAC in pediatricsOf 645 mechanically ventilated patients admitted, 22 (3.4%) met criteria for VAC - incidence 0.829%, lower than the 2.3% to 11.5% reported in adult studiesPatients with VAC experienced -a significantly longer mean length of stay in the PICU ( days vs days; P )and higher mean total ventilator time ( h vs h; P ).significant association between tracheostomy and VAC ( P < .000) and between chronic ventilator dependence and VAC ( P < .002).cultured microorganisms: Gram-negative rods 71%; staphylococcal or streptococcal species 26%Of those with two or more potentially causative pathogens - 67% (n=4) were in patients with a tracheostomyCHEST 2013; 144(1):32–38
50 References:Virkki R, Juven T, Rikalainen H, Svedström E, Mertsola J, Ruuskanen O. Differentiation of bacterial and viral pneumonia in children. Thorax ;57(5):438.Tan TQ, Mason EO Jr, Barson WJ, Wald ER, Schutze GE, Bradley JS, Arditi M, Givner LB, Yogev R, Kim KS, Kaplan SL. Clinical characteristics and outcome of children with pneumonia attributable to penicillin-susceptible and penicillin-nonsusceptible Streptococcus pneumoniae. Pediatrics. 1998;102(6):1369.Finnegan OC, Fowles SJ, White RJ. Radiographic appearances of mycoplasma pneumonia. Thorax. 1981;36(6):469.Korppi M, Kiekara O, Heiskanen-Kosma T, Soimakallio S. Comparison of radiological findings and microbial aetiology of childhood pneumonia. Acta Paediatr. 1993;82(4):360.Simpson W, Hacking PM, Court SD, Gardner PS. The radiological findings in respiratory syncytial virus infection in children. II. The correlation of radiological categories with clinical and virological findings. Pediatr Radiol. 1974;2(3):155.Dawson KP, Long A, Kennedy J, Mogridge N. The chest radiograph in acute bronchiolitis. J Paediatr Child Health. 1990;26(4):209.Bachur R, Perry H, Harper MB. Occult pneumonias: empiric chest radiographs in febrile children with leukocytosis. Ann Emerg Med ;33(2):166.Margolis P, Gadomski A. The rational clinical examination. Does this infant have pneumonia? JAMA. 1998;279(4):308.Klompas M. Complications of Mechanical Ventilation — The CDC’s New Surveillance Paradigm. NEJM 2013:368;16Meyers, J., Shook, J., Pella, J., & Cron, S. G. Complete respiratory assessment score accurately predicts outcomes in children with acute reactive airway disease exacerbations [Abstract]. Academic Emergency Medicine, 1996: 3(5), 396.Rosenfeld M, Gibson RL, McNamara S, Emerson J, Burns JL, Castile R, Hiatt P, McCoy K, Wilson CB, Inglis A, Smith A, Martin TR, Ramsey BW. Early pulmonary infection, inflammation, and clinical outcomes in infants with cystic fibrosis. Pediatr Pulmonol. 2001;32(5):356.
51 References contEmerson J, Rosenfeld M, McNamara S, Ramsey B, Gibson RL. Pseudomonas aeruginosa and other predictors of mortality and morbidity in young children with cystic fibrosis. Pediatr Pulmonol. 2002;34(2):91.Speert DP. Advances in Burkholderia cepacia complex. Paediatr Respir Rev. 2002;3(3):230.Fauroux B, Hart N, Belfar S, BouléM, Tillous-Borde I, Bonnet D, Bingen E, Clément A. Burkholderia cepacia is associated with pulmonary hypertension and increased mortality among cystic fibrosis patients. J Clin Microbiol. 2004;42(12):5537.Kalish LA, Waltz DA, Dovey M, Potter-Bynoe G, McAdam AJ, Lipuma JJ, Gerard C, Goldmann D. Impact of Burkholderia dolosa on lung function and survival in cystic fibrosis. Am J Respir Crit Care Med. 2006;173(4):421.Rosenfeld M, Emerson J, Williams-Warren J, Pepe M, Smith A, Montgomery AB, Ramsey B. Defining a pulmonary exacerbation in cystic fibrosis. J Pediatr. 2001;139(3):359.Aaron SD, Vandemheen KL, Ferris W, Fergusson D, Tullis E, Haase D, Berthiaume Y, Brown N, Wilcox P, Yozghatlian V, Bye P, Bell S, Chan F, Rose B, Jeanneret A, Stephenson A, Noseworthy M, Freitag A, Paterson N, Doucette S, Harbour C, Ruel M, MacDonald N. Combination antibiotic susceptibility testing to treat exacerbations of cystic fibrosis associated with multiresistant bacteria: a randomised, double-blind, controlled clinical trial. Lancet. 2005;366(9484):463.Waters V, Ratjen F. Combination antimicrobial susceptibility testing for acute exacerbations in chronic infection of Pseudomonas aeruginosa in cystic fibrosis. Cochrane Database Syst Rev. 2008Simon RH. Cystic fibrosis: Antibiotic therapy for lung disease. UpToDate (found at: therapy-for-lung-disease?source=search_result&search=cystic+fibrosis+and+pneumonia&selectedTitle=1%7E150)Saiman L, Siegel J, Cystic Fibrosis Foundation Consensus Conference on Infection Control Participants. Infection control recommendations for patients with cystic fibrosis: Microbiology, important pathogens, and infection control practices to prevent patient-to-patient transmission. Am J Infect Control. 2003;31(3 Suppl):S1.
52 References con’tCystic Fibrosis Foundation, Borowitz D, Robinson KA, Rosenfeld M, Davis SD, Sabadosa KA, Spear SL, Michel SH, Parad RB, White TB, Farrell PM, Marshall BC, Accurso FJ. Cystic Fibrosis Foundation evidence-based guidelines for management of infants with cystic fibrosis. J Pediatr ;155(6 Suppl):S73.Brook I. Bacterial Colonization, Tracheobronchitis, and Pneumonia following Tracheostomy and Long-Term Intubation in Pediatric Patients. CHEST 1979: 76:Simpson VS, Bailey A, Higgerson RA and Christie L M. Ventilator-Associated Tracheobronchitis in a Mixed Medical/Surgical Pediatric ICU. CHEST 2013; 144(1):32–38Nseir S, Di Pompeo C, Soubrier S, et al . Effect of ventilatorassociated tracheobronchitis on outcome in patients without chronic respiratory failure: a case-control study . Crit Care 2005 ; 9 ( 3 ): R238 - R245 .Agrafi otis M Siempos II, Falagas ME . Frequency, prevention, outcome and treatment of ventilator-associated tracheobronchitis: systematic review and meta-analysis . Respir Med ; 104 ( 3 ):Dallas J, Skrupky L, Abebe N, Boyle WA III, Kollef MH . Ventilator-associated tracheobronchitis in a mixed surgical and medical ICU population . Chest ; 139 ( 3 ):Kun SS, Edwards JD, Davidson Ward SL, Keens TG. Hospital Readmissions for Newly Discharged Pediatric Home Mechanical Ventilation Patients. Pediatr Pulmonol. 2012; 47:409–414.Graf JM, Montagnino BA, Hueckel R, McPherson ML. Pediatric tracheostomies: a recent experience from one academic center. Ped Crit Care Med Jan;9(1):Fishman JA. Pulmonary infections in immunocompromised patients. Found at: immunocompromised-patients?source=search_result&search=pneumonia+in+immunocompromised&selectedTitle=2%7E150Fishman JA, Rubin RH. Infection in organ-transplant recipients. N Engl J Med. 1998;338(24):1741.
53 Bradley, J. S. , Byington, C. L. , Shah, S. S. , Alverson, B Bradley, J. S., Byington, C. L., Shah, S. S., Alverson, B., Carter, E. R., Harrison, C., et al.. The management of communityacquired pneumonia in infants and children older than 3 months of age: Clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clinical Infectious Diseases 2011: 53(7), e25-e76.Michelow, I. C., Olsen, K., Lozano, J., Rollins, N. K., Duffy, L. B., Ziegler, T., et al. (2004). Epidemiology and clinical characteristics of communityacquired pneumonia in hospitalized children. Pediatrics, 2004:113(4),S.A. Friedberg, T.E. Griffith, G.M. Hass. Histologic changes in the trachea following tracheostomy. Ann Otol Rhinol Laryngol, 74 (1965), pp. 785– 798M.S. Niederman, R.D. Ferranti, A. Zeigler et al. Respiratory infection complicating long term tracheostomy. The implication of persistent gram- negative tracheobronchial colonization. Chest, 85 (1984), pp. 39–44J.G. Barlett, L.G. Faling, S. Willey. Quantitative Tracheal bacteriologic and cytologic studies in patients with long term tracheostomies. Chest, 74 (1978), pp. 635–639Graf J, Stein F. Tracheitis in pediatric patients. Semin Pediatr Infect Dis 2006:17:11.Brilli RJ, Sparling KW, Lake MR, Butcher J, Myers, SS, Clark MD, Helpling A, Stutler ME.The Business Case for Preventing Ventilator-Associated Pneumonia in Pediatric Intensive Care Unit Patients. The Joint Commission Journal on Quality and Patient Safety 2008: 34(11) 629.