Prevention of Ventilator Associated Pneumonia Safe Critical Care Project Vanderbilt-HCA Collaborative

Ventilator Associated Pneumonia (VAP) - Key Points - VAP is the 2nd most common nosocomial infection = 15% of all hospital acquired infections Incidence = 9% to 70% of patients on ventilators Increased ICU stay by several days Increased avg. hospital stay 1 to 3 weeks Mortality = 13% to 55% Added costs of $40,000 - $50,000 per stay Centers for Disease Control and Prevention, 2003. Rumbak, M. J. (2000). Strategies for prevention and treatment. Journal of Respiratory Disease, 21 (5), p. 321;

Challenge and Controversy “There is no doubt that the diagnosis and management of VAP remains one of the most controversial and challenging topics in management of critically ill patients.” Chan C, Chest 2005;127:425

Changing Views of VAP No longer just an “unfortunate” occurrence Viewed as medical error Institute of Medicine Leapfrog Group JCAHO – hospitals required to show VAP prevention/reduction measures

Diagnosing VAP VAP is a Nosocomial Pneumonia = Hospital acquired Diagnosis is imprecise and usually based on a Combination of: Clinical factors - fever or hypothermia; change in secretions; cough; apnea/bradycardia; tachypnea Microbiological factors - positive cultures of blood/sputum/tracheal aspirate/pleural fluids CXR factors - new or changing infiltrates

DiagnosingVAP Diagnosis of VAP can be a confusing and complicated process. In order to clarify the process and help clinicians, the Centers for Disease Control and Prevention (CDC) published guidelines for diagnosing VAP in 2003 *Guidelines for Preventing Health-Care--Associated Pneumonia, 2003 * http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm These guidelines were revised and updated in a joint statement published by the American Thoracic Society and the Infectious Diseases Society of America * Am J Respir Crit Care Med 171:388-416, 2005

Diagnosing VAP For this project, we used the revised guidelines to developed tools to help clinicians with making the diagnosis. Am J Respir Crit Care Med 171:388-416, 2005

Bad Bugs: Pathogens in VAP (1) Pathogens that cause VAP differ depending on whether the condition occurs early (less than 96 hours after intubation or admission to ICU) or late (greater than 96 hours after intubation or admission to ICU) Kollef M, Chest 2005;128:3854-62

Bad Bugs: Pathogens in VAP (2) Early–Onset Pneumonia (< 96 hours of intubation or ICU admission) Community-acquired Pathogens: Streptococcus pneumoniae Haemophilus influenzae Staphylococcus aureus Antibiotic-sensitive

Bad Bugs: Pathogens in VAP (3) Late-Onset Pneumonia (> 96 hours of intubation or ICU admission) Hospital-acquired Pathogens: Pseudomonas aeruginosa Methicillin resistant Staphylococcus aureus (MRSA) Acinetobacter Enterobacter Antibiotic-resistant Kollef M, Chest 2005;128:3854-62

Risk Factors for Nosocomial Pneumonia Major risk factor = mechanical intubation Factors that enhance colonization of the oropharynx &/or stomach: Administration of antibiotics Admission to ICU Underlying chronic lung disease Conditions favoring aspiration into the respiratory tract or reflux from GI tract: Supine position *GERD NGT placement *Coma/delirium Intubation and self-extubation Immobilization Surgery of head/neck/thorax/upper abdomen

Risk Factors for Nosocomial Pneumonia (cont’d) Conditions requiring prolonged use of mechanical ventilatory support with potential exposure to contaminated respiratory devices &/or contact with contaminated hands Host Factors: Extremes of age Malnutrition Immunocompromised Underlying condition/disease process Cook D et al, Ann Intern Med 1998;129:433-40

Diagnosing VAP: using flow diagrams as guides Four diagrams Algorithm #1: Adolescents and adults Algorithm #2: Immunocompromised pt. Algorithm #3: Children 1 to <12 years Algorithm #4: Infants (<1 year)

Algorithm #2: Diagnosing VAP in Immunocompromised Patients

Algorithm #3: Diagnosing VAP in Children (Age >1 and <13 years)

Algorithm #4: Diagnosing VAP in Infants (Age <1 year old)

VAP Antibiotic Selection (introductory comments) Considerations in making selection Setting (community, NH, hospital) Suspected organism (GNRs, GPCs) Host factors (immunosuppression) Local susceptibility patterns Initial empiric and broad; subsequent narrowing Concept is to not miss the organism with initial coverage and then de-escalate when able

Selected references Centers for Disease Control and Prevention Guidelines for Preventing Healthcare-Associated Pneumonia, 2003, [http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm] Cook D et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med 1998 Sep 15;129(6):433-40. Dodek, P and the Canadian Critical Care Trials Group. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med. 2004 Aug 17;141(4):305-13.   Guidelines for the management of hospital-acquired, ventilator-associated and healthcare-associated pneumonia. Joint statement the American Thoracic Society and the Infectious Diseases Society of America. Am J Respir Crit Care Med 2005, 171:388-416. Kollef M, epidemiology and outcomes of healthcare-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest 2005,128:3854-62. Langley JM, Bradley JS. Defining pneumonia in critically ill infants and children. Pediatr Crit Care Med 2005, 6[supplement]:S9-S13. Rumbak, M. J. Strategies for prevention and treatment. Journal of Respiratory Diseases, 2000, 21(5):321-327.

Ventilator associated Pneumonia Next webcast will focus on Ventilator Bundle: Interventions to prevent or reduce VAP Check lists to help the patient care team Discussion of antibiotic choices Webcast