Pneumonia Phenotypes by Feldman

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

The Alphabet Soup of Pneumonia - TopicsThe Alphabet Soup of Pneumonia - Topics
Community Nosocomial
CAP VAT
CABP VAE
NHAP VAC
HCAP IVAC
HAP VAP
Other

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

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

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

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

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

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

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

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

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

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

100
80
60
40
20
0
0 20 40
100-Specifity
80 100
Sensitivity
New scoring
system
Current
HCAP
criteria

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

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

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

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%)
GC-HCAPGC-HCAP
therapy (8.0%)therapy (8.0%)
non-GC therapynon-GC therapy
(16.3%)(16.3%)
Guideline Concordant Therapy and HCAPGuideline Concordant Therapy and HCAP

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
15071
5 (3-6)
12.6
23.3

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
P<0.001
P<0.001
P=0.39

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
P<0.001
P<0.001

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

COMMUNITY-ACQUIRED
CABP
CAP in the elderly
CAP in the younger patient
CAP in COPD patients
Aspiration pneumonia
Other Considerations

 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

HOSPITAL-ACQUIRED PNEUMONIA
VENTILATOR-ASSOCIATED
VA Tracheobronchitis (VAT)
VA Event (VAE)
VA Condition (VAC)
Infection-related VAC (IVAC)
VAP
Other Considerations

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

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

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
VAP Rates in the USAVAP Rates in the USA

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)
CDC Clinical Definition for VAPCDC Clinical Definition for VAP
Fever (>38°C or
>100.4o
F)

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

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

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

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
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

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
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

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

Did not meetDid not meet
criteriacriteria
n=39n=39
criteriacriteria
n=52n=52
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

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

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

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

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
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
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
-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
-0.01 (-0.57, 0.55)
28-day mechanical ventilation-
free days
2 431 Mean Difference
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

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

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

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