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TURKISH THORACIC SOCIETY. HOSPITAL ACQUIRED PNOMONIAE CONSENSUS STATEMENT,2008. Oğuz KILINÇ (Chair) Turhan ECE (Secretary) Dilek ARMAN Nahit ÇAKAR Nedim ÇAKIR Ali GÜNERLİ Eyüp Sabri UÇAN - PowerPoint PPT Presentation
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TURKISH THORACIC SOCIETY
HOSPITAL ACQUIRED PNOMONIAE CONSENSUS STATEMENT,2008
AUTHORS
Oğuz KILINÇ(Chair) Turhan ECE (Secretary) Dilek ARMAN Nahit ÇAKAR Nedim ÇAKIR
Ali GÜNERLİ
Eyüp Sabri UÇAN
Sercan ULUSOY
Haluk VAHAPOĞLU
COMMITTEE MEMBERS
Halis AKALIN Füsun ALATAŞ Feza BACAKOĞLU Kadir BİBEROĞLU Semra ÇALANGU Haluk C. ÇALIŞIR Hülya ELLİDOKUZ
Zeynep GÜLAY Selma KARABEY Volkan KORTEN Emine OSMA
Metin ÖZKAN
Halit ÖZSÜT Tülay YARKIN
NEW DEFINITION
Healthcare-associated pneumoniae (HCAP)
Nosocomial tracheobronchitis Ventilator-associated
tracheobronchitis
NEW DEFINITION
Healthcare- associated pneumoniae; Hospitalization for 2 d or more in the preceding
90 d Residence in a nursing home or extended care
facility Home infusion therapy (including antibiotics) Chronic dialysis within 30 d Home wound care Family member with multidrug-resistant
pathogen
NEW DEFINITION
Nosocomial tracheobronchitis*
When fever, leukocytosis, purulent sputum, and a positive culture of a sputum or tracheal aspirate are present without a new lung infiltrate,
*Occurs 48 hours or more afteradmission, which was not incubating at the time of admission
NEW DEFINITION
Ventilator- associated tracheobronchitis * When fever, leukocytosis,
purulent sputum, and a positive culture of a sputum or tracheal aspirate are present without a new lung infiltrate
*Occurs 48 hours or more aftermechanically ventilation, which was not incubating at the time of MV
PATHOGENESIS
Aspiration of oropharyngeal pathogens,
Inhalation Hematogenous spread
ETIOLOGY
Early- onset (3.-4. day) Streptococcus pneumoniae, Haemophilus influenzae Methicilline sensitive Staphylococcus
aureus’tur Late- onset (after 5 day)
P. aeruginosa Acinetobacter spp. Enterobacter spp. Klebsiella spp. MRSA
RISK FACTORS (increased mortality)
Inappropriate treatment Previous antibiotic usage Duration of hospital stay and ICU Prolonged MV Multilober and/or bilateral pulmoner infiltration Severity of underlying diseases APACHE II, SAPS Severe sepsis/septic shock, multiorgan disfunction
syndrom (MODS) Elderly age (>65) PaO2/FiO2< 240
RISK FACTORS (increased mortality)
MDR pathogens P. aeruginosa Acinetobacter spp* Stenotrophomonas maltophilia S. aureus(methicilline resistant) MRSA
DIAGNOSIS- Clinical
New or progressive infiltrate on chest x-ray and
> 38 0C fever Leukocytosis or Leukopenia Purulen sputum Decline in oxygenation
DIAGNOSIS-CPIS Clinical Pulmonary Infection Score (CPIS)
DeğişkenlerScore 0 Score1 Score 2
Fever 0C ≥36.1, ≤ 38.4 ≥ 38.5, ≤ 38.9 ≥ 39, ≤ 36
WBC count μ/L ≥4000, ≤ 11.000 <4000, >11.000
Secretions Absent Present,nonpurulent Present purulent
PaO2/ FiO2 > 240 or ARDS <240 and without ARDS
Chest x-ray İnfiltration absent Diffuse or patchy infiltrate
Localized infiltrate
Microbiology No or light growth Moderate or heavy growth*1 point for same organism on Gram stain
CPIS > 6 is often regarded as consistent with a diagnosis of pneumonia especially in VAP
DIAGNOSIS- first step tests
Sputum,pleural fluid, tracheal secretion culture
Two step, blood culture
DIAGNOSIS- second step tests
BAL PSB TTA FNAB Open lung biopsy
CLASSIFICATION AND TREATMENT
GROUP 1 Early- onset
GROUP 2 Late- onset (risk factors for mortality
and MDR pathogen (-) GROUP 3
Early-onset /Late onset (risk factors for mortality and for MDR pathogen (+)
Pathogens
A-MDR pathogen riskB-Risk factors for mortality C- HCAP
Group 1(Early onset)A B C absent
Group 2(Late onset)
A B C absent
Grup 3Early-onset or late
onset( A and/or B and/or C
present)
Core pathogens:S. pneumoniaeH. influenzaeM.catarrhalis
A.S.aureus ( methicilline sensitive)
Enterobacter spp.K. pneumoniaeS. marcescensE. coliOther Gram negative rods +S. aureus (methicilline sensitive)
Core pathogens
P.aeruginosa,Acinetobacter spp. S.aureus (methicilline resistant)K.pneumoniaeS. maltophilia +Group 2 pathogens
CLASSIFICATION AND TREATMENT
Group 1 (Monotherapy)
Ampisilin-Sulbaktam/ Co-amoksilavor
Cefuroxime/Ceftriaxoneor
Levofloxacin/ Moksifloxacin *
Group 2 (Monotherapy)
Sulbaktam- ampicilline
or
Ceftriaxone/Cefotaxime
or
Ofloxacine
or
Levofloxacin/Moksifloxacin
or
Piperacillin-tazobaktam
Group 3 (Monotherapy/ Combination)Piperacillin- tazobaktam
orCeftazidim, Cefepime, Cefoperazon-Sulbaktam
orImipenem, Meropenem
Amicasin or Ciprofloxacin
orColistin**
Linezolid***, Teikoplanin, Vankomycine
*Combination therapy for MDR pathogens. After 72 hrs If CPIS ≤6 swicth monotherapy ** Especially in MDR pathogens***Don’t use Linezolid empirically
DURATION OF TREATMENT
If patients receive an initially appropriate antibiotic regimen, efforts should be made to shorten the duration of therapy from the traditional 14 to 21 days to periods as short as 7 days, provided that the etiologic pathogen is not P. aeruginosa, and that the patient has a good clinical response (CPIS ≤6) with resolution of clinical features of infection
RESPONSE TO THERAPY
Resolution of fever Clinical improvement WBC count PaO2/ FiO2 improvement CPIS ≤ 6 CRP value decrease %40 at 4. day
Prevention
Hospital Infection Association Turkish Thoracic Society
“Guidelines for Prevention of Hospital Acquired pneumonia”