power point Pneumonia.3ppt

7/25/2019 power point Pneumonia.3ppt

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Noscocomial Pneumonia

Andrew Shorr, MD, MPH


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Overview

Definition

Pathogenesis

Risk factors

Microiolog!

Diagnosis "reatment


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Definition

#nfection of $ulmonar! $araench!ma

Occurs %&'() hrs after admission

*+cludes $rocesses incuating $rior to

admission


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*$idemiolog!

Occurs in '-. cases $er -,... admissions

#ncidence /'). fold higher in M0 $atients

Second most common nosocomial infection

Mortalit! rate a$$roaches (.1

Attriutale mortalit!2 33'.1


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Pathogenesis

Host defenses im$aired

#noculum sufficient to cause infection enterslower res$irator! tract

0irulent organism


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Pathogenesis

Routes of entr!

4Microas$iration

4#nhalation

4Hematogenous s$read

4Direct e+tension

40ia *" tue


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Pathogenesis

Microas$iration

4Most common route of entr!

4OP flora in hos$itali5ed $atients is distinct

4Ma! as$irate 6# contents

4Occurs in %1 of health! su7ects during slee$

431 of moderatel! ill and (1 of #89 $atientsoro$har!n+ coloni5ed ! *6N:


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Pathogenesis

6ross as$iration2 rare

Aerosol2 ;egionella, M":

*" tue

4:!$ass host defenses aove cords

4#m$airs mucocilliar! clearance

4Secretions leak around *" tue


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Risk factors Patient'related

4Age

48NS status

49nderl!ing disease


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Microiolog! S$ectrum different from 8AP

Organisms de$end on2

4"ime of onset

4Severit!4Patient's$ecific factors g> immune status=

6enerall! concerned aout2

4*6N:

4S> aureus

4Pol!microial in .1 $atients on M0


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8lassif!ing $atients

*arl! onset2 ? da!s after admission

;ate onset2 @ da!s after admission

Determine risk factors

Determine severit!


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8lassif!ing $atients

O n s e t A n ! t i m e

N o


e s

R i s k B a c t o r s

M i l d t o M o d e r a t e

* a r l ! O n s e t ; a t e O n s e t

N o


e s

R i s k B a c t o r s

S e v e r e

S e v e r i t ! o f # l l n e s s


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Risk factors

Pathogen Risk factors

Anaroes Adominal surger!,

as$iration

S> aureus 8oma, AODM, renal

failure

;egionella 8orticosteroids

Psuedomonas ;ong #89 sta!,corticosteroids,

underl!ing lung d5,

$rior a+ use


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Definition of severe HAP

Admission to #89

Res$irator! failure


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Microiolog!

Mild to moderate HAP or earl! severe HAP

4*nteroacter

4* coli

4Proteus

4Serratia

4MSSA


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Microiolog!

Severe HAP

4Psuedomonas

4Acinetoacter

4MRSA


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Microiolog!

Risk factor for S> aureus

48oma on admission

468S ? for at least )%hrs after admission

4Asence of corticosteroid t+

4Recent trauma


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Microiolog! Risk factors for ;egionella

4Malignanc!

4Neutro$enia

49se of corticosteroids

4Renal failure

48!toto+ic chemothera$!

No relationshi$ with

4MS

4Prior a+ use


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Diagnosis

8linical $icture often confusing

Differential diagnosis road

Role for invasive $rocedure controversial

No diagnostic a$$roach without $rolems


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8CR

New infiltrate often reEuired for d+ of HAP

Bever ma! $recede infiltrate

AP films difficult to inter$ret in #894)/1 of infiltrates ! 8" scan missed ! 8CR

4#f underl!ing 8CR anormal g> ARDS=,

locating new $rocess difficult Man! $neumonia mimics


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8CR

As$iration Alveolar hemorrhage

Atelectasis Pulmonar! edema

ARDS Pleural effusion

Pulmonar!

infarct

:OOP

Radiogra$hic Mimics of Pneumonia


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8CR

Atelectasis

48ommon

4Resolves within %& hrs

6astric as$iration

4.1 of alert $ts on M0 ma! as$irate

4((1 as!m$tomatic des$ite large volume

as$iration


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8CR

No feature allows differentiation of

$neumonia from non$neumonic $rocess

8orrelation etween 8CR diagnosis and

auto$s! $oor

Providing radiologist with clinical data ma!

worsen accurac! of 8CR


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S$utum culture

Onl! 331 of $atients coloni5ed develo$

HAP

Recover! of $athogen from tracheal

secretion not diagnostic for $neumonia


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S$utum culture

6ram stain4#f no acteria, ?1 $roailit! HAP

4#f @-.Foil immersion field on .1 HAP


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8linical im$ression

New infiltrate, $urulent secretion GF'

feverFleukoc!tosis2 3.1 incidence HAP

Overall MD accurac!2 ((1

4*+clude d+ HAP '' &1

4D+ HAP '' /)1

*ven if clinical d+ HAP correct, incorrect

a+ in %%1 cases

Bagon et al> 8hest> -32 %('3>


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:ronchosco$!

"wo techniEues4PS:


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:ronchosco$!

Positive culture2 -.3or -.%8B9

Pneumonia usuall! not clinicall! $resent unless -.%

8B9 or greater

"hreshold not asolute 8ulture results elow threshold ma! re$resent earl!

disease

43.1 of $atients with @-.)ut ? -.38B9 eventuall!

develo$ed HAP

S$ecificit!2 .1 for :A; and PS:


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:ronchosco$!

0

10

20

30

40

50

60

70

80

Culture Threshold

FalsePositive(%)

ETA

A!

P"

S$ecificit! and Balse Positives

-.3 -.% -. -./

"orres et al> ARRD> -32 )'(>


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Diagnosis

Sensitivit!2 '(1

Balse negative rate raises concern aout

withholding a+

4No e+cess mortalit! in $atients with neg> BO:

even if clinical $icture cFw HAP


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"reatment

Never use aminogl!coside alone

4Poor lung $enetration

uinolones and aminogl!cosides have$rolonged $ostantiiotic effect

Anti$seudomonal thera$! reEuires multi$le

agents Iith a$$ro$riate thera$!2 (.'&.1 survival


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"reatment

*6N:

4 *nteroacter

4 *> coli

4 Jlesiella

4 Proteus4 Serratia

MSSA

8e$halos$orin

4 )nd generation or

non$suedomonal 3rd

generation

:eta lactamFlactamase

inhiitor

BluroEuinolone

Core or#a$is%s Core a$ti&ioti's

Mild to moderate HAP, no unusual risk factors,onset an! time or severe HAP with earl! onset


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"reatment

Anaroes S> aureus

;egionella

Pseudomonas

8lindam!cin or eta

lactamF lactamase

inhiitor

GF' 0ancom!cin

Macrolide BluroEuinolone

Core or#a$is%sPlus Core a$ti&ioti'sPlus

Mild to moderate HAP with risk factors, onset an!time


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"reatment

Pseudomonas

Acinetoacter

8onsider MRSA

Aminogl!coside BluroEuinolone

A5treonam

Anti$suedomonal

P8N or 8e$halos$orin

#mi$enim


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"reatment Design2 D:R8", Multicenter

Patients

48linical d+ of nosocomial $neumonia

4Stratified ! severit! illness


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"reatment

0

10

20

30

40

5060

70

80

+0

Trova,lo-a'i$

Ci)ro,lo-a'i$

*fficac! All 8ause

Mortalit!

8ure Rate for

Psuedomonas

1 of

Patients


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"reatment

Design2 D:R8", multicenter

Patients

4Mechanicall! ventilated

48linical d+ GF' :A;

Sam$le si5e2 nK)(

#ntervention

48efe$ime G amikacin vs cefta5idime G amikacin

:eaucaire 6, et al> Ann Anesth Reanim -L-&2 -&/'-


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"reatment

0

10

20

30

40

50

60

.e'over*

rate

All Patie$ts /o'u%e$ted

P$eu%o$ia

Ce,taidi%e

Ce,e)i%e

$ K .>.


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Drug resistance

6rowing $rolem

8ara$enems no longer acce$tale

monothera$! for 0AP Historical use of a+ likel! cul$rit

Resistance now an issue for

4Pseudomonas4S> aureus

4Acinetoacter


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Acinetoacter resistance

Acinetoacter 0AP associated with high

mortalit!

Recent #89 outreaks of MDR A>aumanni re$orted

Ma7or risk factor for infection with A

umanni48efta5idime use .=

Husni RN, et al> 8H*S" -L --2-3(&'-3&)


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Prevention

#nfection control


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Prevention

8hoice of ulcer $ro$h!la+is

4Sucralfate vs ranitidine 8ro$ rotation of antiiotics

Selective gut decontamination

9se of c!tokines46'8SB

4#BN

Co$troversial a$d e-)eri%e$tal o)tio$s


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8onclusions

HAP is freEuent

HAP associated with e+cess mortalit!

Pathogens distinct

Diagnosis is difficult

A$$roach to thera$! em$iric

Prevent o$tions availale

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