Pneumonia Phenotypes –Pneumonia Phenotypes –
the Alphabet Soupthe Alphabet Soup
Charles Feldman
Professor of Pulmonology a...
The Alphabet Soup of Pneumonia - TopicsThe Alphabet Soup of Pneumonia - Topics
Community Nosocomial
CAP VAT
CABP VAE
NHAP ...
Pneumonia occurring >48 hours after endotracheal intubation
Risk factors for MDR bacteria causing VAP
 Presence of HCAP o...
First introduced in 1978 by GARB et al
 Has become an accepted phenotype
 Leading cause of morbidity in nursing home res...
Pneumonia occurring ≤48 hours of hospital admission in patients
with ≥1 of the following risk factors for MDR bacteria as ...
Included in IDSA/ATS guideline for NP in 2005
 Essentially NHAP patients and patients with co-morbid illness
who have hos...
0 5 10 15 20 25
Patient mortality
Kolief MH, et al. Chest 2005;128 3854
Micek S, et al. Antimicrob Agents Chemother 2007;5...
Mortality from Multi-drug Resistant Infections
 Maybe MDR pathogens represent more
invasive pathogens
 Partly related to...
Proposed Algorithm for HCAP TherapyProposed Algorithm for HCAP Therapy
Severe pneumonia
Assess severity of illness (need f...
Isolated Pathogens in CAP and HCAP Patients
Gram-positive pathogens
MRSA
MSSA
Streptococcus pneumoniae
Gram-negative patho...
Disease Severity and Clinical
Outcomes in CAP and HCAP Patients
Disease severity
CURB65
Pneumonia
Severity index
Clinical ...
0
20
40
60
80
PaientswithPDRpathogens(%)
0
n=165
1
n=77
2
n=93
4
n=4
Number of HCAP risk factors
P > 0.01 for trend
0
20
4...
100
80
60
40
20
0
0 20 40
100-Specifity
80 100
Sensitivity
New scoring
system
Current
HCAP
criteria
Park SC et al. Respira...
Causative Microorganisms in each HCAP Group
MicroorganismMicroorganism HCAP with ≥2 MDRHCAP with ≥2 MDR
risk factorsrisk f...
20
18
16
14
12
10
8
6
4
2
0
%
CAP
5.6
HCAP with 0-1
MDR risks
8.6
HCAP with ≥2
MDR risks
18.2
P = 0.346
P = 0.012
Maruyama...
Definitions of CAP and HCAP GuidelineDefinitions of CAP and HCAP Guideline
Concordant Therapy (not ICU patients)Concordant...
62 682 pneumonia patients assessed for inclusion62 682 pneumonia patients assessed for inclusion
47 611 (76.0%) patients e...
Overall Health Outcomes
OverallOverall
Patients , n
LOS, d
30-day mort.
90-day mort.
GC-CAPGC-CAPGC-HCAPGC-HCAP Non-GCNon-...
40
35
30
25
20
15
10
5
0
Bacterialpathogens(%)
S. pneumoniae S. aureus Pseudomonas
1 risk factor, n=1045 2 risk factors, n...
35
30
20
25
15
10
5
0
Mortality(%)
30-day 90-day
1 risk factor,
n=11673
2 risk factors,
n=3079
≥3 risk factors,
n=319
30-d...
Characteristics of the Included Studies
CharcteristicsCharcteristics
TotalTotal
DesignDesign
ProspectiveProspective
Retros...
COMMUNITY-ACQUIRED
CABP
CAP in the elderly
CAP in the younger patient
CAP in COPD patients
Aspiration pneumonia
Other...
 In the ER, CAP should be suspected on the
grounds of typical clinical symptoms/signs
and confirmed with chest radiograph...
HOSPITAL-ACQUIRED PNEUMONIA
VENTILATOR-ASSOCIATED
VA Tracheobronchitis (VAT)
VA Event (VAE)
VA Condition (VAC)
Infecti...
Nasopharyngeal colonizationNasopharyngeal colonization
Background secretionsBackground secretions
Leak around ETT cuffLeak...
VAP Rates in Selected CountriesVAP Rates in Selected Countries
20
18
16
14
12
10
MeanVAPsper1000ventilatordays
6
4
2
0
8
U...
10.0
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
2004 2005 2006 2007 2008 2009
1500
2000
1000
2500
3000
500
0
VAPcasesper1000v...
New onset of purulent sputum or
change in character of sputum or
increased respiratory secretions
or increased suctioning
...
Simplified Version of the CPISSimplified Version of the CPIS
ValueValueComponentComponent
Temperature °C
PointsPoints
≥ 36...
Diagnostic Accuracy of CPIS: A Meta-analysisDiagnostic Accuracy of CPIS: A Meta-analysis
Detailed evaluation
14
Detailed e...
Tejerina
Pellosi
Pham
Veinstein
Fartoukh
Fábrega
s
Carolina
Luyt
Jung
Ramirez
Croce
Luyt
Flanagan
2010
2008
2007
2006
2003...
Tejerina
Pellosi
Pham
Veinstein
Fartoukh
Fábrega
s
Carolina
Luyt
Jung
Ramirez
Croce
Luyt
Flanagan
2010
2008
2007
2006
2003...
Tejerina
Pellosi
Pham
Veinstein
Fartoukh
Fábrega
s
Carolina
Luyt
Jung
Ramirez
Croce
Luyt
Flanagan
2010
2008
2007
2006
2003...
VAE Definition Algorithm Summary
Respiratory
status
component
Patient on mechanical ventilation >2 days
Baseline period of...
Did not meetDid not meet
criteriacriteria
n=39n=39
Did not meetDid not meet
criteriacriteria
n=52n=52
Did not meetDid not ...
1.0
0.8
0.4
0.2
0.0
0.2 0.4 0.6 0.8 1.00.0
Sensitivity
0.6
1-Specificity
0.2 0.4 0.6 0.8 1.00.0
1-Specificity
CPIS WBC
sTR...
1.0
0.8
Sensitivity
0.2 0.4 0.6 0.8 1.0
1-Specificity
0.6
0.4
0.2
0.0
0.0
PCT + CPIS
CPISPCT
Ref line
Prognostic Value in ...
Initial Empirical Therapy for VAPInitial Empirical Therapy for VAP
CeftriaxoneCeftriaxone
oror
Levofloxacin, moxifloxacin ...
Short course vs. Prolonged Antibiotic TherapyShort course vs. Prolonged Antibiotic Therapy
No. of studiesNo. of studies No...
Pharmacologic-based Strategies for Prevention of VAPPharmacologic-based Strategies for Prevention of VAP
Topical iseganan
...
Non-pharmacologic-based strategies for prevention of VAPNon-pharmacologic-based strategies for prevention of VAP
StrategyS...
Upcoming SlideShare
Loading in …5
×

ICN Victoria: Feldman on "Pneumonia in ICU"

927 views

Published on

ICN Victoria presents Professor Charles Feldman on Pneumonia in ICU - eating your way through the alphabet soup.

Published in: Health & Medicine
  • Be the first to comment

ICN Victoria: Feldman on "Pneumonia in ICU"

  1. 1. Pneumonia Phenotypes –Pneumonia Phenotypes – the Alphabet Soupthe Alphabet Soup Charles Feldman Professor of Pulmonology and Chief Physician Charlotte Maxeke Johannesburg Academic Hospital University of the Witwatersrand
  2. 2. The Alphabet Soup of Pneumonia - TopicsThe Alphabet Soup of Pneumonia - Topics Community Nosocomial CAP VAT CABP VAE NHAP VAC HCAP IVAC HAP VAP Other
  3. 3. Pneumonia occurring >48 hours after endotracheal intubation Risk factors for MDR bacteria causing VAP  Presence of HCAP or HAP risk factors for MDR VAP Pneumonia occurring > 48 hours after hospital admission Risk factors for MDR bacteria causing HAP  Antibiotic therapy within 90 days of infection  Current hospitalization of ≥5 days  High frequency of antibiotic resistance in community or specific hospital unit  Immunosuppressive disease of therapy Presence of HCAP risk factors for MDR HAP Anand N et al. Semin Respir Crit Care Med 2009; 30: 3-9 The Alphabet Soup of PneumoniaThe Alphabet Soup of Pneumonia Pneumonia occurring ≤ 48 hours of hospital admission in patients who do not meet the criteria for HCAP CAP
  4. 4. First introduced in 1978 by GARB et al  Has become an accepted phenotype  Leading cause of morbidity in nursing home residents and frequently a terminal event  Most patients have one (89-97%) or more co-morbidities – especially neurological and/or cardiac  Fewer typical symptoms and confusion common  Frequently more severe – clinical and risk scores  Controversy regarding aetiology, although pneumococcus is a leading cause and GNB and SA rare  Mortality is higher NHAP Klapdor B et al. Eur Respir Monogr 2014; 63: 105-116 The Alphabet Soup of PneumoniaThe Alphabet Soup of Pneumonia
  5. 5. Pneumonia occurring ≤48 hours of hospital admission in patients with ≥1 of the following risk factors for MDR bacteria as cause of infection:  Hospitalization for ≥ 2 days in acute-care facility within 90 days of infection  Residence in a nursing home or long-term care facility  Antibiotic therapy, chemotherapy, or wound care within 30 days of current infection  Haemodialysis treatment at a hospital or clinic  Home infusion therapy or home wound care  Family member with infection due to MDR bacteria HCAP The Alphabet Soup of PneumoniaThe Alphabet Soup of Pneumonia Anand N et al. Semin Respir Crit Care Med 2009; 30: 3-9
  6. 6. Included in IDSA/ATS guideline for NP in 2005  Essentially NHAP patients and patients with co-morbid illness who have hospital contact and antibiotics – greater risk of MDR pathogens  Based on a few, mainly USA, studies  Not found in subsequent studies in USA, Japan, Korea and Europe  Recent meta-analysis demonstrated similar mortality when adjusted for co-morbidity  No link between MDR pathogens and mortality – functional status more important driver of mortality  Reject as possible phenotype HCAP The Alphabet Soup of PneumoniaThe Alphabet Soup of Pneumonia Klapdor B et al. Eur Respir Monogr 2014; 63: 105-116
  7. 7. 0 5 10 15 20 25 Patient mortality Kolief MH, et al. Chest 2005;128 3854 Micek S, et al. Antimicrob Agents Chemother 2007;51:3568 Carratala J, et al. Arch Intern Med 2007;167 1393 P=0.007 P<0.001 P<0.001 CAP HCAP Mortality in Patients with CAP and HCAPMortality in Patients with CAP and HCAP Anand N et al. Semin Respir Crit Care Med 2009; 30: 3-9
  8. 8. Mortality from Multi-drug Resistant Infections  Maybe MDR pathogens represent more invasive pathogens  Partly related to inappropriate choice of empiric antibiotic therapy  Partly related to the underlying diseases that are putting patients at risk of MDR pathogens that also place them at greater risk of a higher mortality
  9. 9. Proposed Algorithm for HCAP TherapyProposed Algorithm for HCAP Therapy Severe pneumonia Assess severity of illness (need for mechanical ventilation, ICU admit) AND Presence of risk factors for MDR pathogens (recent antibiotics, recent hospitalization, poor functional status, immune suppression) HCAP is present: From a nursing home, recent hospitalization, haemodialysis, home infusion therapy No Yes Group 1 (0 – 1 risks) Treat for common CAP pathogens (consider oral Rx) Quinolone or β- lactam / macrolides. Group 2 (≥ 2 risks) Consider hospital. Treat for MDR pathogens with HAP therapy. Group 3 (0 risks) Treat for severe pneumonia in hospital. β-lactam PLUS macrolide or quinolone. Group 4 (≥ 1 risks) Treat for MDR pathogens with HAP recommendations. Use 3 drugs. Brito V et al. Curr Opin Infect Dis 2009; 22: 316-325
  10. 10. Isolated Pathogens in CAP and HCAP Patients Gram-positive pathogens MRSA MSSA Streptococcus pneumoniae Gram-negative pathogens Pseudomonas aeruginosa Escherichia coli Haemophilus influenzae Klebsiella pneumoniae Enterobacter species Acinetobacter baumannii Stenotrophomonas maltophilia Others Atypical pathogens Mycoplasma pneumoniae Legionella pneumophila Fungal pathogens 9 (5.2) 15 (8.7) 55 (32.0) 23 (13.4) 2 (1.2) 4 (2.3) 26 (15.1) 4 (2.3) 1 (0.6) 2 (1.2) 10 (5.8) 26 (15.1) 1 (0.6) 1 (0.6 CAP (n=172) HCAP (n=167) 18 (10.8) 11 (6.6) 22 (13.2) 35 (21.0) 5 (3.0) 2 (1.2) 45 (26.9) 9 (5.4) 4 (2.4) 2 (1.2) 12 (7.2) 5 (3.0) 0 (0) 1 (0.6) P-value 0.059 - <0.001 0.064 - - 0.007 - - - - <0.001 - - Park SC et al. Respiratory Medicine 2012; 106: 1131-1319
  11. 11. Disease Severity and Clinical Outcomes in CAP and HCAP Patients Disease severity CURB65 Pneumonia Severity index Clinical outcomes In-hospital ICU admission Duration of stay (days) 1.6 ± 1.2 101.3 ± 40.7 27 (15.7) 46 (26.7) 20.3 ± 29.2 1.7 ± 1.1 116.3 ± 31.6 47 (28.1) 47 (28.1) 24.2 ± 37.9 0.349 <0.001 0.006 0.773 0.289 CAP (n=172) HCAP (n=167) P-valueTreatment Park SC et al. Respiratory Medicine 2012; 106: 1131-1319
  12. 12. 0 20 40 60 80 PaientswithPDRpathogens(%) 0 n=165 1 n=77 2 n=93 4 n=4 Number of HCAP risk factors P > 0.01 for trend 0 20 40 60 80 0 - 2 n=185 Total score P > 0.01 for trend 3 - 5 n=95 ≥ 6 n=59 Risk of PDR Pathogens in HCAPRisk of PDR Pathogens in HCAP Park SC et al. Respiratory Medicine 2012; 106: 1131-1319
  13. 13. 100 80 60 40 20 0 0 20 40 100-Specifity 80 100 Sensitivity New scoring system Current HCAP criteria Park SC et al. Respiratory Medicine 2012; 106: 1131-1319
  14. 14. Causative Microorganisms in each HCAP Group MicroorganismMicroorganism HCAP with ≥2 MDRHCAP with ≥2 MDR risk factorsrisk factors (n = 170)(n = 170) HCAP with 0-1HCAP with 0-1 MDR risk factorMDR risk factor (n = 151)(n = 151) PP valuevalue S. pneumoniae 59 (39.1) 47 (27.6) 0.03 S. aureus 7 (4.6) 30 (17.6) <0.001 MRSA 0 22 (12.9) <0.001 Enterobacteriaceae 4 (2.6) 21 (12.4) 0.001 P. aeruginosa 3 (2.0) 19 (11.2) 0.001 M. catarrhalis 4 (2.6) 0 0.048 MDR pathogens 3 (2.0) 47 (27.1) <0.001 Influenza virus 8 (5.3) 1 (0.6) 0.012 Maruyama T et al. Clin Infect Dis 2013; 57: 1373-1383
  15. 15. 20 18 16 14 12 10 8 6 4 2 0 % CAP 5.6 HCAP with 0-1 MDR risks 8.6 HCAP with ≥2 MDR risks 18.2 P = 0.346 P = 0.012 Maruyama T et al. Clin Infect Dis 2013; 57: 1373-1383 30-day Mortality in CAP versus HCAP
  16. 16. Definitions of CAP and HCAP GuidelineDefinitions of CAP and HCAP Guideline Concordant Therapy (not ICU patients)Concordant Therapy (not ICU patients) β-lactam + macrolide Respiratory fluoroquinolone CG-CAP therapyCG-CAP therapy CG-HCAP therapyCG-HCAP therapy Antipseudomonal β-lactam + antipseudomonal fluoroquinolone + vancomycin or linezolid Antipseudomonal β-lactam + aminoglycoside plus vancomycin or linezolid Attridge RT et al. Eur Respir J 2011; 38: 878-887
  17. 17. 62 682 pneumonia patients assessed for inclusion62 682 pneumonia patients assessed for inclusion 47 611 (76.0%) patients excluded47 611 (76.0%) patients excluded 40 557 (85.2%) did not meet criteria for HCAP40 557 (85.2%) did not meet criteria for HCAP 46 27 (9.7%) critically ill46 27 (9.7%) critically ill 2 924 (63.2% admitted to ICU2 924 (63.2% admitted to ICU 1 550 (33.5%) respiratory and/or CV organ failure1 550 (33.5%) respiratory and/or CV organ failure 51 (1.1% mechanically ventilated (invasive)51 (1.1% mechanically ventilated (invasive) 102 (2.2% prescribed vasopressors)102 (2.2% prescribed vasopressors) 2 427 (5.1%) did not receive antibiotics within 48 hours2 427 (5.1%) did not receive antibiotics within 48 hours 15071 (24.0%) with HCAP15071 (24.0%) with HCAP 1 2408 received1 2408 received GC-HCAPGC-HCAP therapy (76.7%)therapy (76.7%) 1 211 received1 211 received GC-HCAPGC-HCAP therapy (8.0%)therapy (8.0%) 2 452 received2 452 received non-GC therapynon-GC therapy (16.3%)(16.3%) Attridge RT et al. Eur Respir J 2011; 38: 878-887 Guideline Concordant Therapy and HCAPGuideline Concordant Therapy and HCAP
  18. 18. Overall Health Outcomes OverallOverall Patients , n LOS, d 30-day mort. 90-day mort. GC-CAPGC-CAPGC-HCAPGC-HCAP Non-GCNon-GC PP-value-value 1211 7 (4-13) 22.8 37.8 GC-HAP vs.GC-HAP vs. GC-CAPGC-CAP GC-HAP vs.GC-HAP vs. non-GCnon-GC 11408 4 (3-7) 9.9 19.8 2452 5 (3-9) 20.1 32.7 <0.001 <0.001 <0.001 <0.001 0.06 0.002 Attridge RT et al. Eur Respir J 2011; 38: 878-887 15071 5 (3-6) 12.6 23.3
  19. 19. 40 35 30 25 20 15 10 5 0 Bacterialpathogens(%) S. pneumoniae S. aureus Pseudomonas 1 risk factor, n=1045 2 risk factors, n=303 ≥3 risk factors, n=42 Bacterial Pathogens in Culture-positive HCAP Attridge RT et al. Eur Respir J 2011; 38: 878-887 P<0.001 P<0.001 P=0.39
  20. 20. 35 30 20 25 15 10 5 0 Mortality(%) 30-day 90-day 1 risk factor, n=11673 2 risk factors, n=3079 ≥3 risk factors, n=319 30-day and 90-day Mortality in HCAP Attridge RT et al. Eur Respir J 2011; 38: 878-887 P<0.001 P<0.001
  21. 21. Characteristics of the Included Studies CharcteristicsCharcteristics TotalTotal DesignDesign ProspectiveProspective RetrospectiveRetrospective Definition of HCAPDefinition of HCAP ATS/DSA definitionATS/DSA definition Alternative definitionAlternative definition GeographyGeography North AmericaNorth America EuropeEurope AsiaAsia Duration of follow-up for outcome assessmentDuration of follow-up for outcome assessment In hospitalIn hospital 30 days30 days UnclearUnclear Quality assessmentQuality assessment GoodGood ModerateModerate PoorPoor Number of studiesNumber of studies 2424 99 1515 55 1919 33 99 1212 1111 1111 22 44 1010 1010 Chalmers JD et al. Clin Infect Dis 2014; 58: 330-339
  22. 22. COMMUNITY-ACQUIRED CABP CAP in the elderly CAP in the younger patient CAP in COPD patients Aspiration pneumonia Other Considerations The Alphabet Soup of PneumoniaThe Alphabet Soup of Pneumonia
  23. 23.  In the ER, CAP should be suspected on the grounds of typical clinical symptoms/signs and confirmed with chest radiograph  In elderly and patients with altered mental state, CAP should be considered even without typical symptoms  Once diagnosed assessment should be made of severity – e.g. PSI, CURB-65, CRB-65  According to risk, site of care should be identified  Assess risk of MDR pathogens  Antibiotic therapy based on severity and MDR risk Approach to CAP ManagementApproach to CAP Management Klapdor B et al. Eur Respir Monogr 2014; 63: 105-116
  24. 24. HOSPITAL-ACQUIRED PNEUMONIA VENTILATOR-ASSOCIATED VA Tracheobronchitis (VAT) VA Event (VAE) VA Condition (VAC) Infection-related VAC (IVAC) VAP Other Considerations The Alphabet Soup of PneumoniaThe Alphabet Soup of Pneumonia Klapdor B et al. Eur Respir Monogr 2014; 63: 105-116
  25. 25. Nasopharyngeal colonizationNasopharyngeal colonization Background secretionsBackground secretions Leak around ETT cuffLeak around ETT cuff ETT BiofilmETT Biofilm Host lung defensesHost lung defensesBacterial pathogensBacterial pathogens Colonization VAT VAP Craven DE et al. Clin Infect Dis 2010; 51: S59-S66
  26. 26. VAP Rates in Selected CountriesVAP Rates in Selected Countries 20 18 16 14 12 10 MeanVAPsper1000ventilatordays 6 4 2 0 8 USA M edical USA Surgical Italy AustriaScotland France Spain Belgium IN ICC Post-intervention Klompas M. Curr Opin Infect Dis 2012; 25: 176-182
  27. 27. 10.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 2004 2005 2006 2007 2008 2009 1500 2000 1000 2500 3000 500 0 VAPcasesper1000ventilatordays NumberofhospitalreportingtoCDC Surgical ICUs Medical ICUs Mean VAP rate Klompas M. Curr Opin Infect Dis 2012; 25: 176-182 VAP Rates in the USAVAP Rates in the USA
  28. 28. New onset of purulent sputum or change in character of sputum or increased respiratory secretions or increased suctioning requirements Two of theTwo of the followingfollowing New or progressive and persistent infiltrate One of theOne of the followingfollowing Two or more serialTwo or more serial radiographs with at leastradiographs with at least one of the followingone of the following New onset of worsening cough or dyspnea, or tachypnea Leukopenia (<4000 WBC/µL) or leukocytosis (>12,000 WBC/ µL ) Consolidation Rales or bronchial breath sounds For adults ≥70 years old, altered mental status with no other recognised cause Cavitation Worsening gas exchange (e.g. oxygen desaturation, increased oxygen requirements, or increased ventilator demand) Klompas M. Curr Opin Infect Dis 2012; 25: 176-182 CDC Clinical Definition for VAPCDC Clinical Definition for VAP Fever (>38°C or >100.4o F)
  29. 29. Simplified Version of the CPISSimplified Version of the CPIS ValueValueComponentComponent Temperature °C PointsPoints ≥ 36.5 and ≤ 38.4 ≥ 38.5 and ≤ 38.9 ≥ 39.0 and ≤ 36.0 ≥ 4 000 and ≤ 11 000 < 4 000 or > 11 000 Blood leukocytes per mm2 0 1 2 0 1 Few Moderate Large Purulent Tracheal secretions 0 1 2 +1 > 240 or presence of ARDS ≤ 240 or absence of ARDS Oxygenation Pao2/Fio2,mm Mg 0 2 No infiltrate Patchy or diffuse infiltrate Localised infiltrate Chest radiograph 0 1 2 Luna C et al. Crit Care Med 2003; 31: 676-682
  30. 30. Diagnostic Accuracy of CPIS: A Meta-analysisDiagnostic Accuracy of CPIS: A Meta-analysis Detailed evaluation 14 Detailed evaluation 14 Assessed with QUADAS 15 Assessed with QUADAS 15 Included in the meta- analysis 13 Included in the meta- analysis 13 Potentially relevant papers retrieved from the databases 19 Potentially relevant papers retrieved from the databases 19 Excluded based on title or abstract 5 Excluded based on title or abstract 5 Excluded irrelevant 10 Excluded irrelevant 10 Additional studies identified in reference lists 11 Additional studies identified in reference lists 11 Excluded insufficient data 2 Excluded insufficient data 2 Shan J et al. Respiratory Care 2011; 56: 1087-1094
  31. 31. Tejerina Pellosi Pham Veinstein Fartoukh Fábrega s Carolina Luyt Jung Ramirez Croce Luyt Flanagan 2010 2008 2007 2006 2003 1999 2004 2004 2010 2008 2006 2008 2000 0.45 0.97 0.33 0.66 0.85 0.77 0.41 0.89 0.85 0.78 0.61 0.59 0.58 0.37- 0.54 0.85- 1.00 0.12- 0.62 0.49- 0.80 0.70- 0.94 0.46- 0.95 0.29- 0.54 0.80- 0.94 0.69- 0.95 0.40- 0.97 0.49- 0.73 0.33- 0.82 0.66- 0.96 95% CISensitivityYearFirst Author Pooled sensitivity = 0.65 (0.61 to 0.69) Chi2 = 115.24; df = 12 (p<0.001) Inconsistency (I2 ) = 89.6% 0 0.2 0.4 0.6 0.8 1 Sensitivity Shan J et al. Respiratory Care 2011; 56: 1087-1094
  32. 32. Tejerina Pellosi Pham Veinstein Fartoukh Fábrega s Carolina Luyt Jung Ramirez Croce Luyt Flanagan 2010 2008 2007 2006 2003 1999 2004 2004 2010 2008 2006 2008 2000 0.60 1.00 0.77 0.54 0.49 0.42 0.77 0.49 0.61 0.80 0.43 0.75 0.91 0.50- 0.69 0.86- 1.00 0.46- 0.95 0.37- 0.71 0.32- 0.65 0.15- 0.72 0.59- 0.90 0.37- 0.57 0.39- 0.80 0.63- 0.92 0.33- 0.54 0.53- 0.90 0.84- 0.95 95% CISensitivityYearFirst Author Pooled sensitivity = 0.64 (0.60 to 0.67) Chi2 = 114.41; df = 12 (p<0.001) Inconsistency (I2 ) = 89.6% 0 0.2 0.4 0.6 0.8 1 Specificity Shan J et al. Respiratory Care 2011; 56: 1087-1094
  33. 33. Tejerina Pellosi Pham Veinstein Fartoukh Fábrega s Carolina Luyt Jung Ramirez Croce Luyt Flanagan 2010 2008 2007 2006 2003 1999 2004 2004 2010 2008 2006 2008 2000 1.25 1094.33 1.67 2.29 5.38 2.38 2.40 6.89 9.02 14.00 1.18 4.29 55.93 0.76-2.07 42.74-28019.31 0.31-8.93 0.91-5.79 1.84-15.71 0.42-13/39 0.91-8.33 3.24-14.66 2.54-31.99 2.37-82.72 0.62-2.25 1.13-16.31 15.35-191.33 95% CISensitivityYearFirst Author Random Effects Model Pooled diagnostic odds ratio = 4.85 (2.42 to 9.71) Cochran-Q = 67.85; df = 12 (p<0.001) Inconsistency (I2 ) = 82.3% Tau2 = 1.2020 0.01 1 100.0 Diagnostic odds ratio Shan J et al. Respiratory Care 2011; 56: 1087-1094
  34. 34. VAE Definition Algorithm Summary Respiratory status component Patient on mechanical ventilation >2 days Baseline period of stability or improvement, followed by sustained period of worsening oxygenation Ventilator-associated condition (VAC) General evidence of infection/inflammation Infection-related ventilation-associated complication (IVAC) Positive or probable VAP Positive results of microbiological testing Infection / inflammation component Additional evidence No CXR needed! After www.cdc.org
  35. 35. Did not meetDid not meet criteriacriteria n=39n=39 Did not meetDid not meet criteriacriteria n=52n=52 Did not meetDid not meet criteriacriteria n=76n=76 EnrolledEnrolled n=10n=10 EnrolledEnrolled n=39n=39 EnrolledEnrolled n=43n=43 SurvivorsSurvivors n=2n=2 NonsurvivorsNonsurvivors n=10n=10 SurvivorsSurvivors n=9n=9 NonsurvivorsNonsurvivors n=6n=6 SurvivorsSurvivors n=3n=3 Nonsurvivors2nNonsurvivors2n =2=2 SepsisSepsis n=259n=259 Respiratory ICURespiratory ICU n=82n=82 Surgical ICUSurgical ICU n=91n=91 Emergency ICUEmergency ICU n=86n=86 VAPVAP n=12n=12 Non-VAPNon-VAP n=31n=31 VAPVAP n=15n=15 Non-VAPNon-VAP n=24n=24 VAPVAP n=5n=5 Non-VAPNon-VAP n=5n=5 Diagnosing VAP in Critically Ill PatientsDiagnosing VAP in Critically Ill Patients Su L-X et al. Am J Crit Care 2012; 21: e110-e119
  36. 36. 1.0 0.8 0.4 0.2 0.0 0.2 0.4 0.6 0.8 1.00.0 Sensitivity 0.6 1-Specificity 0.2 0.4 0.6 0.8 1.00.0 1-Specificity CPIS WBC sTREM-1PCT Ref line sTREM-1 + CPIS sTREM-1 + WBC Ref line A B Diagnostic Value in VAPDiagnostic Value in VAP Su L-X et al. Am J Crit Care 2012; 21: e110-e119
  37. 37. 1.0 0.8 Sensitivity 0.2 0.4 0.6 0.8 1.0 1-Specificity 0.6 0.4 0.2 0.0 0.0 PCT + CPIS CPISPCT Ref line Prognostic Value in VAPPrognostic Value in VAP Su L-X et al. Am J Crit Care 2012; 21: e110-e119
  38. 38. Initial Empirical Therapy for VAPInitial Empirical Therapy for VAP CeftriaxoneCeftriaxone oror Levofloxacin, moxifloxacin orLevofloxacin, moxifloxacin or ciprofloxacinciprofloxacin oror Ampicillin/sulbactamAmpicillin/sulbactam oror EtrapenemEtrapenem Antipseudomonal cephalosporin (cefepime, ceftazidime) or Antipseudomonal carbepenem (imipenem or meropenem) or β-lactam/β-lactamase inhibitor (piperacillin- tazobactam) plus Antipseudomonal fluroquinolone (ciprofloxacin or levofloxacin) or Aminoglycoside (amikacin, gentamicin or tobramyicin) plus Linezolid or vancomycin (if risk factors for MRSA are present) VAP with no risk factors for MDR pathogens VAP with risk factors for MDR pathogens Joseph NM et al. Eur J Int Med 2010; 21: 360-368
  39. 39. Short course vs. Prolonged Antibiotic TherapyShort course vs. Prolonged Antibiotic Therapy No. of studiesNo. of studies No. of participantsNo. of participants Statistical methodStatistical method Effect sizeEffect sizeOutcome/ subgroup titleOutcome/ subgroup title 28-day mortality 2 431 Odds Ratio (M-H, Random, 95% CI) 1.08 (0.66, 1.76) Recurrence of pneumonia 3 508 Odds Ratio (M-H, Random, 95% CI) 1.37 (0.87, 2.17) 28-d antibiotic-free days 2 431 Mean Difference (IV, Random, 95% CI) 4.02 (2.26, 5.78) ITU mortality 2 107 Odds Ratio (M-H, Random, 95% CI) 0.85 (0.37, 1.91) Non-res. of pneumonia 1 77 Odds Ratio (M-H, Fixed. 95% CI) 0.89 (0.49, 7.40) In-hospital mortality 1 401 Odds Ratio (M-H, Fixed, 95% CI) 1.09 (0.71, 1.67) Recurrence - multi-resistant organism 1 110 Odds Ratio (M-H, Fixed. 95% CI) 0.44 (0.21, 0.95) Duration of ITU stay 2 431 Mean Difference (IV, Random, 95% CI) -0.01 (- 2.30, 2.27) Duration of hospital stay 1 30 Mean Difference (IV, Fixed, 95% CI) -1.0 (-4.11, 2.11) Duration of mech. ventilation 2 107 Mean Difference (IV, Random, 95% CI) -0.01 (-0.57, 0.55) 28-day mechanical ventilation- free days 2 431 Mean Difference (IV, Random, 95% CI) 0.47 (-0.97, 1.92) Mortality-associated with VAP 1 77 Mean Difference (IV, Fixed, 95% CI) 1.0 (-8.85, 10.95) Pugh R et al. Cochrane Database of Systematic Reviews 2012, Issue 2
  40. 40. Pharmacologic-based Strategies for Prevention of VAPPharmacologic-based Strategies for Prevention of VAP Topical iseganan Orodigestive decontamination (topical/topical + IV antibiotics) Oral chlororohexidine Aerosolized antibiotics IV antibiotics Specific stress ulcer prophylaxis regimen Short-course antibiotic therapy (when clinically applicable) Routine antibiotic cycling/rotation/heterogeneity Restricted (conservative) blood transfusion Vaccines (influenza, pneumococcal) StrategyStrategy No No Yes Nil Nil No Yes No Yes Yes RecommendationRecommendation 1 1 1 1 1 1 1 2 2 1 Evidence levelEvidence level Kollef MH. Surgical Infections 2011; 12: 211-220
  41. 41. Non-pharmacologic-based strategies for prevention of VAPNon-pharmacologic-based strategies for prevention of VAP StrategyStrategy RecommendationRecommendation Evidence levelEvidence level Non-invasive mask ventilation Avoid re-intubation Avoid patient transports Orotracheal intubation preferred Orogastric intubation preferred Early tracheostomy Routine ventilator circuit changes Heat-moisture exchanger Closed endotracheal suctioning Subglottic secretion drainage Shorter duration mechanical-ventilation Adequate ICU staffing Silver-coated endotracheal tube Polyurethane endotracheal tube cuff Semi-erect positioning Rotational beds Chest physiotherapy Use of protocols/bundles Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 1 2 2 1 2 1 1 1 1 1 1 2 1 1 1 1 1 2 Kollef MH. Surgical Infections 2011; 12: 211-220

×