Respiratory Tract Infections Across the continuum

Karen Hoover, RN, IPC CoordinatorMSIPC Fundamentals, 2015

Abuse alcohol Have had chest surgery or other major surgery Have a weak immune system from cancer

treatment, certain medicines, or severe wounds Have long-term (chronic) lung disease (i.e. COPD) Breathe saliva or food into their lungs as a result

of not being fully alert or having swallowing problems (for example, after a stroke)

Have been in the hospital for a long time. Are taking many antibiotics Are older

Hospital Pneumonia Risk if:

Hospitalization in an acute care hospital for two or more days in the last 90 days;

Residence in a nursing home or long-term care facility in the last 30 days

Receiving outpatient intravenous therapy (like antibiotics or chemotherapy) within the past 30 days

Receiving home wound care within the past 30 days Attending a hospital clinic or dialysis center in the last 30 days

Having a family member with known multi-drug resistant pathogens (MRDO)

Risk increases when:

Estimates of Healthcare-Associated Infections Occurring in Acute Care Hospitals in the United States, 2011

Major Site of Infection Estimated No.

Pneumonia 157,500Gastrointestinal Illness 123,100Urinary Tract Infections 93,300Primary Bloodstream Infections 71,900Surgical site infections from any inpatient surgery 157,500

Other types of infections 118,500Estimated total number of infections in hospitals 721,800

Mental changes or confusion (often 1st sign in elderly) Fever and chills A cough with greenish or pus-like phlegm (sputum) General discomfort, uneasiness, or ill feeling

(malaise) Loss of appetite Nausea and vomiting Sharp chest pain that gets worse with deep

breathing or coughing Shortness of breath Decreased blood pressure and fast heart rate

Signs and symptoms:

Pulse oximetry, to measure oxygen levels in the blood

Arterial blood gases, to measure oxygen levels in the blood

Blood cultures, to see if the infection has spread to the blood

Chest x-ray or CT scan, New or progressive infiltrate

Complete blood count (CBC) Leukocytosis> 10.000 cells/μl

Sputum culture or sputum gram stain, to check what germs are causing the pneumonia. Purulent sputum or

“change in sputum”

Exams and tests:

Bacterial pneumonia: The majority of cases related to various gram negative bacilli (52%) and S. aureus (19%), usually of the MRSA type. Others are Haemophilus spp. (5%). In the ICU results were S. aureus(17.4%), P. aeruginosa(17.4%), Klebsiella pneumoniae and Enterobacter spp. (18.1%), and Haemophilus influenzae(4.9%).

Viral pneumonia: influenza and respiratory syncytial virus (RSV) and, in the immunocompromised host, cytomegalovirus (CMV)- cause 10-20% of infections.

Mycoplasma Pneumonia: not viruses or bacteria, but they have traits common to both.

Other: affect immune-compromised individuals. PCP pneumocystis carinii pneumonia.

Types:

Legionnaires disease (L. pneumophila) Pertussis (Bordetella pertussis) Aspergillosis (Aspergilllus spp. Viral infections:

◦Common cold viruses◦Influenza◦Respiratory syncytial virus

Other Types of Respiratory Tract Infections

Pharyngitis:◦inflammation of the pharynx. It

frequently results in a sore throat. Pharyngitis may be caused by a variety of microorganisms.

◦Group A Streptococcus or S. pyogenes – “strep throat”

Sinusitis: inflammation or infection of the sinuses

Other Infections of the Respiratory tract

Bronchitis: inflammation of the main air passages (bronchi). ◦Symptoms - cough, shortness of breath

and chest tightness.

◦Two main types: acute and chronic. Acute: caused by cold viruses Chronic: type of COPD; long-term

condition

Other Infections of the Respiratory tract

Pathogenesis of Healthcare Associated Pneumonia:Oral Cavity + Airway = Predominant Source of Microbes

Endotracheal tube bypasses upper respiratory tract defenses, allows for pooling of oropharyngeal secretions, prevents effective cough.

Bacteria enter lower respiratory tract via aspiration from:◦ Oropharynx (majority)◦ Hematogenous spread (?GI tract – maybe but

unproven) Factoid: 45% of non-hospitalized adults aspirate

during sleep Home CPAP machines Risks in Healthcare settings:

◦ Abnormal swallowing◦ Depressed level of consciousness◦ Mechanical Ventilation◦ Thoracic and abd. surgery

Steps in Pathogenesis of Pneumonia

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm

Acute care - ◦ Prolonged length of stay

(3-6d)◦Excess cost/case =

up to $40k◦Associated mortality

= 20-33% LTC –

◦ 1st or 2nd most common site of infection

◦ Seasonal variation, more frequent during influenza season

◦ Associated mortality = 6-23%

HAP Morbidity & Mortality

1. CDC. 2. Bartlett JG et al. Clin Infect D. Am J Respir Crit Care Med 2005

Various Types of Pneumonia

Acute Care:◦Gram negatives:

Acinetobacter Pseudomonas, etc.

◦ Gram Positives, less so but: S. aureus

◦ Early onset can incl.- S. pneumoniae H. influenzae E. coli, Klebsiella

LTC:◦ 79% of cases – no

pathogen isolated◦ S. pneumoniae 0-

39%,◦ S. aureus 0-33%, ◦ H. influenzae in 0-19%◦ aerobic Gram-

negative bacilli in 0-55%

Etiologic Agents: HAP

Ventilator-Associated Event (VAE) For use in adult patients (≥ 18 years)

Patient on mechanical ventilation > 2 days

Baseline period of stability or improvement, followed by sustained period of worsening oxygenation .

Ventilator-Associated Condition (VAC)

General, objective evidence of infection/inflammation

Infection-Related Ventilator-Associated Complication (IVAC) Positive results of laboratory/microbiological testing

Possible or Probable VAP

Ventilator-Associated Events (VAE)

VAEs are identified by using a combination of objective criteria: deterioration in respiratory status after a period of stability or improvement on the ventilator, evidence of infection or inflammation, and laboratory evidence of respiratory infection.

Ventilator-Associated Condition (VAC) Patient has a baseline period of stability

or improvement on the ventilator, defined by ≥ 2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values. The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2.

Pt Name MRN/LOC D 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31PEEP 5

MV-1/25 6ICU-6 FiO2 1 70

PEEP 15 15 8MV-1/29 6ICU-9B FiO2 3 100 60 50

PEEP 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5MV -1/11 6ICU-10 FiO2 21 MRSA SPUTUM/URINE 80 70 70 60 50 50 50 50 40 50 40 40 40 40 40 40 40 40 40 40 40

PEEP 5 5 5 5 5 5 5 5 5 5 5MV - 1/21 NICU-1 FiO2 11 50 40 40 40 40 40 40 40 40 40 40

PEEP 5 5 5 5 5 5 8 8 8 8 8 8 8 8 8 8 8 8 8 8MV-1/12 NICU-2 FiO2 20 60 60 60 60 60 60 60 60 50 50 60 60 60 60 55 55 55 55 55 55

PEEP 5 5 5MV-1/29 NICU-3 FiO2 3 100 50 50

PEEP 5 5 5 5 5 5 5 5 5 7 9 9MV- 1/20 NICU-4 FiO2 12 40 50 50 50 50 50 50 50 50 50 40 40

PEEP 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5MV - 1/15 NICU-6 FiO2 17 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 45

PEEP 5 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 5 5 5 5 5 5 7 7MV-1/8 NICU-7 FiO2 24 50 50 50 50 40 40 40 40 40 40 40 40 40 40 40 40 50 50 50 50 50 50 40 40

VAE WORKSHEET - JANUARY

VAC

Infection-related Ventilator-Associated Complication (IVAC)

Patient meets criteria for VAC

AND … On or after calendar day 3 of mechanical ventilation and

within 2 calendar days before or after the onset of worsening oxygenation, the patient meets both of the following criteria:

1) Temperature > 38 °C or < 36°C, OR white blood cell count ≥ 12,000 cells/mm3 or ≤ 4,000 cells/mm3.

AND 2) A new antimicrobial agent(s) is started, and is continued

for ≥ 4 calendar days.

Develops 48 hours or longer after mechanical ventilation

There is no minimum period of time that the ventilator must be in place in order for the PNEU to be considered ventilator-associated.

Ventilator-Associated Pneumonia (VAP) Rate per 1,000 Ventilator Days

Track the measure monthly

nhsn.cdc.gov/nhsndemo/help/Patient_Safety_Component/Site_Definitions/Clinically_Defined_Pneumonia_PNU1.htm

Ventilator-associated pneumonia (VAP)

VENTILATOR ASSOCIATED EVENTQ-1 2015

  JANUARY FEBRUARY MARCH

  VAC IVAC Poss VAP Prob VAP VAC IVAC Poss VAP Prob VAP VAC IVAC Poss VAP Prob VAP

                         

6 ICU 0 2 0 0 1 2 0 0 1 0 0 0

SICU 1 1 0 0 0 0 0 0 0 0 0 0

NICU 1 1 0 0 1 0 0 0 2 0 0 0

TICU 1 0 1 0 2 0 0 0 0 1 0 0

CCU 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 3 4 1 0 4 2 0 0 3 1 0 0

VAE's   8   6 4

Summary

VAC 10

IVAC 7

Poss VAP 1

Prob VAP 0

   

Total VAE's 18

Physician’s diagnosis of pneumonia alone is not an acceptable criterion for nosocomial pneumonia.

Pneumonia due to gross aspiration (for example, in the setting if intubation in the emergency room or operating room) is considered nosocomial if it meets any specific criteria and was not clearly present or incubating at the time of admission to the hospital

Multiple episodes of nosocomial pneumonia may occur in critically ill patients with lengthy hospital stays.  When determining whether to report multiple episodes of nosocomial pneumonia in a single patient, look for evidence of resolution of the initial infection.  The addition of or change in pathogen alone is not indicative of a new episode of pneumonia.  The combination of new signs and symptoms and radiographic evidence or other diagnostic testing is required.

Applicable to All Pneumonia Specific Site Criteria

Hand Hygiene

Pneumonia Vaccine According to the CDC, adults 50-64 are nearly as likely to get pneumococcal disease as people 65 and older.

Enhancing host defense: flu immunization

Sterilization or Disinfection and Maintenance of Equipment and Devices: ventilator, breathing circuits, etc.

Standard Precautions: mask with open artificial airway suctioning

Prevent Aspiration – elevate head of the bed

Prevent post-op pneumonia: early mobility

Good oral hygiene

Pneumonia Prevention Guidelines

Pneumococcal,

Haemophilus influenzae type b (Hib),

Pertussis (whooping cough),

Varicella (chickenpox),

Measles, and

Influenza (flu) vaccine.

6 vaccines to help prevent pneumonia:

ORAL CARE INTERVENTIONS IN ACUTE CARE

4 Hour Bundle

Subglottic suctioning performed ◦ No remaining secretions above ET tube cuff◦ Store Yankauer in container with airflow – Do not

place on bed

Oral cavity cleansed with suction swab

Mucosa moisturized with swab◦ To assess dryness use gloved finger and touch

buccal mucosa ◦ Offer moisturizer a la cart if not using a company

package

Tooth brushing Subglottic suctioning performed Ensure proper ETT cuff inflation > two minutes Do not have to use toothpaste Use soft toothbrush making small circular movements Remove all visible plaque and soft debris Clean tongue, gums and palate Clean toothbrush with water removing visible debris Store toothbrush upright in container with airflow

(available for purchase or not)

12 Hour Bundle

ID S A G U I D E L I N E S published August 30, 2011

When Does a Child or Infant With CAP Require Hospitalization?

When Should a Child With CAP Be Admitted to an Intensive Care Unit (ICU) or a Unit With Continuous Cardiorespiratory Monitoring?

What Diagnostic Laboratory and Imaging Tests Should Be Used in a Child With Suspected CAP in an Outpatient or Inpatient Setting?

What Additional Diagnostic Tests Should Be Used in a Child With Severe or Life-Threatening CAP?

www.childrensdayton.org/cms/resource_library/files/e17d60ba472 318ab 

Pneumonia in Infants and Children Older Than 3 Months of Age

Patients Requiring Hospitalization

Inpatient Workup: All pt’s should have CXR Blood culture CBC ESR/CRP Urinary antigen for Pneumococcal infection is

not recommended Sputum samples if able (weak; low evidence) Rapid tests for Influenza and viruses should

be used Mycoplasma pneumoniae should be tested

for if suspicious No reliable test for Chlamydophila

pneumoniae

Criteria for admission to an ICU

Criteria for admission to an ICU:

Inpatient Treatment of Pneumonia For the fully immunized child in regions that

do not demonstrate high-level pneumococcal penicillin resistance:◦ Ampicillin or Penicillin G are first-line◦ Azithromycin for suspected atypical pneumonia

(with a beta-lactam if diagnosis is in question)◦ Vancomycin or clindamycin should be added

when S. aureus is suspected by labs, clinical findings or imaging

◦ Ceftriaxone or cefotaxime are alternatives