Prevention ofLower RespiratoryTract Infections

Learning objectives

1. Explain the relevance of pneumonia in health care institutions.

2. Outline elements for defining HAI pneumonia.

3. Identify risk factors for pneumonia.4. Describe the measures for prevention

of pneumonia.

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Time involved

• 35-40 minutes

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Key points

• Pneumonia causes morbidity and mortality and increased utilisation of resources

• Prevention is vital• Prevention includes

• hand hygiene• use of gloves• daily assessment of weaning from a ventilator• elevation of the bed head• orotracheal intubation• oral care with an antiseptic solution• cleaning and disinfection of equipment

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Introduction• In healthy individuals the lower

respiratory tract is sterile• Cough reflex, respiratory mucosa,

secretions, and immunity prevent microorganisms in the LRT

• Impaired conditions of patients and incorrect practices contribute to healthcare-associated pneumonia

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The problem• Pneumonia accounts for 11% - 15% of HAI and

25% of infections in ICUs • Highest mortality among HAIs • Postoperative pneumonia - a common

complication of surgery• Ventilator–associated pneumonia occurs in 8-

28% of patients• Prolongs hospitalisation and antibiotic use • Microorganisms often multidrug-resistant

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Healthcare-associated PneumoniaDEFINITION

• LRT infection that appears during hospitalisation in a patient who was not incubating the infection at admission

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DiagnosisIt is diagnosed by the following:

• rales or bronchial breath sounds• fever• purulent sputum, cough, dyspnoea, tachypnea• relevant radiologic changes• preferably, microbiological diagnosis from bronchial

lavage, transtracheal aspirate, or protected brush culture

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Categories*There are three pneumonia categories:

•PNU1 • X-ray changes and clinical signs and symptoms

laboratory findings •PNU2

• X-ray changes, clinical signs and symptoms, microbiological results

•PNU3• pneumonia in immuncompromised

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SurveillanceFor surveillance purposes, many practitioners use the pneumonia definition published by the U.S. Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN)

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Mechanical ventilation• Impairs normal removal of

mucus and microorganisms from the lower airway

• H2 blocking agents associated with colonisation of gastrointestinal tract and oropharynx

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PathogenesisMicroorganisms may be introduced into the LRT via contaminated equipment or staff hands

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Risk Factors

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Condition of patient

Severely ill, e.g., septic shockSurgery (chest/abdomen) injuriesAgeCardiopulmonary disease Cerebrovascular accidentsLung diseaseComa

Heavy smoker

Therapy

SedationGeneral anaesthesiaTracheal intubationTracheostomyEnteral feedingMechanical ventilationBroad spectrum antibioticH2 blockersImmunosuppressive and cytotoxic drugs

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Time of onset

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Early-onset pneumonia

Four days of admission (in ICUs or after surgery)

Late-onset pneumonia

More than 4 days after admission

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Etiological agentsEarly-onset pneumonia Late-onset pneumonia

Streptococcus pneumoniae Pseudomonas aeruginosa

Haemophilus influenzae Acinetobacter spp.

Moraxella catarrhalis Enterobacter spp.

Methicillin- sensitive Staphylocoocus aureus

Methicillin- resistant Staphylococcus aureus

Influenza Multidrug - resistant organisms Respiratory syncytial or other respiratory viruses

Candida spp.

Aspergillus spp.

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Considerations• Many late-onset VAPs caused by multi-resistant

microorganisms• In immunocompromised patients microbes:

• Viruses (RSV, influenza)• Fungi (Candida spp. and Aspergillus)• Legionella

• from air conditioning or water supplies

• Pneumocystis carinii (AIDS patients) • Mycobacteria

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NHSN survey - causes of VAP in USA

S. Aureus25%

Pseudomonas17%

Enterobacter9%

Acinetobacter9%

Klebsiella8%

E coli5%

Candida3%

Other25%

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Survey in 12 European countries 2008*

S. Aureus16%

Pseudomonas18%

Enterobacter7%

Acinetobacter4%Klebsiella

8%

E coli9%

Candida8%

Other29%

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*European Centre for Disease Prevention and Control (ECDC)

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Prevention

Recommendations are designed to avoid the three mechanisms by which pneumonia develops:

• aspiration• contamination of the aerodigestive tract • contaminated equipment

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Prevention of postoperative pneumonia• Treat lung disease prior to surgery• Elevate head of the bed• Avoid unnecessary suctioning• Provide regular oral cavity care• Encourage deep breathing and coughing• Provide pain therapy (non-sedative)• Use percussion and postural drainage to

stimulate coughing• Encourage early mobilisation

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Prevention of VAP - 1• Hand hygiene before and after contact with

patient or respiratory secretions• Gloves when handling secretions• Sterile gloves for aspiration and tracheostomy

care• Sterile suction catheter• Daily assessments of readiness to wean.• Minimise the duration of ventilation and

noninvasive whenever possible

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Prevention of VAP - 2• Elevate the head of the bed• Avoid gastric over-distension• Avoid unplanned extubation• Orotracheal intubation• Avoid H2 agents and proton pump inhibitors• Regular oral care with an antiseptic solution• Sterile water to rinse respiratory equipment.• Remove condensate, keep the circuit closed• Change ventilator circuit only when necessary

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Prevention of VAP - 3• Store and disinfect respiratory

equipment • Surveillance for VAP • Direct observation of

compliance• Educate healthcare personnel• Establish antibiotic regimens in

accordance with the local situation

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References - 1

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131. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R.

Guidelines for preventing health-care associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recom Rep 2004; 53:1-36. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm

2. American Thoracic Society; Infectious Disease Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Amer J Respir Crit Care Med 2005; 171:388-416. http://ajrccm.atsjournals.org/ cgi/reprint/171/4/388

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References - 2

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131. Coffin S, Klompas M, Classen D et al. Strategies to

prevent ventilator- associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol 2008; 29:S31-S40.

2. Kollef M. Prevention of hospital-associated pneumonia and ventilator– associated pneumonia. Crit Care Med 2004; 32:1396-1405.

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Further reading1. Allegranz B, Nejad SB, Combescure C, Graafmans W,

Attar H, Donaldson L, Pittet P. Burden of endemic health-care-associated infection in developing countries: systematic review and meta- analysis. Lancet 2011; 377: 228 – 241.

2. Ding J-G, Qing-Feng S, Li K-C, Zheng M-H, et al. Retrospective analysis of nosocomial infections in the intensive care unit of a tertiary hospital in China during 2003 and 2007. BMC Infect Dis 2009; 9:115.

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Quiz1. Most cases of hospital pneumonia are not preventable.

T/F?2. The main strategy to prevent VAP is

a) Treatment of respiratory diseasesb) Routine culture of patientsc) Minimise duration of mechanical ventilationd) Isolation of infected patients in ICU

3. Regarding prevention of VAP, which is incorrect?a) Change circuits of mechanical ventilation only if is necessaryb) Elevate head of the bed if not contraindicatedc) Gloves when handling respiratory secretionsd) Use of antimicrobial prophylaxis always in patients with

mechanical ventilation

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International Federation of Infection Control• IFIC’s mission is to facilitate international networking in

order to improve the prevention and control of healthcare associated infections worldwide. It is an umbrella organisation of societies and associations of healthcare professionals in infection control and related fields across the globe .

• The goal of IFIC is to minimise the risk of infection within healthcare settings through development of a network of infection control organisations for communication, consensus building, education and sharing expertise.

• For more information go to http://theific.org/

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