Pneumonia Phenotypes by Feldman

Pneumonia Phenotypes Pneumonia Phenotypes – the Alphabet Soup– the Alphabet Soup

Charles Feldman

Professor of Pulmonology and Chief PhysicianCharlotte Maxeke Johannesburg Academic Hospital

University of the Witwatersrand

The Alphabet Soup of Pneumonia - TopicsThe Alphabet Soup of Pneumonia - TopicsThe 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 PneumoniaThe 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<0.001CAP

HCAP

Mortality in Patients with CAP and HCAPMortality in Patients with CAP and HCAPMortality in Patients with CAP and HCAPMortality in Patients with CAP and HCAP


Mortality from Multi-drug Resistant InfectionsMortality 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 TherapyProposed Algorithm for HCAP TherapyProposed Algorithm for HCAP Therapy

Severe pneumoniaSevere 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 PatientsIsolated 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)

CAP(n=172)

HCAP(n=167)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-valueP-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 and Clinical Outcomes in CAP and HCAP Patients

Disease severity

CURB65

Pneumonia

Severity index

Clinical outcomes

In-hospital

ICU admission

Duration of stay (days)

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

1.6 ± 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

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

0.349

<0.001

0.006

0.773

0.289

CAP

(n=172)

CAP

(n=172)

HCAP

(n=167)

HCAP

(n=167)

P-valueP-valueTreatmentTreatment


0

20

40

60

80P

aie

nts

with

PD

R p

ath

oge

ns (

%)

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 HCAPRisk of PDR Pathogens in HCAPRisk of PDR Pathogens in HCAP


100

80

60

40

20

0

0 20 40

100-Specifity

80 100

Sen

sitiv

ityNew scoring

system

Current HCAP criteria


Causative Microorganisms in each HCAP GroupCausative Microorganisms in each HCAP Group

MicroorganismMicroorganism HCAP with ≥2 MDR HCAP with ≥2 MDR risk factorsrisk factors

(n = 170)(n = 170)

HCAP with 0-1 HCAP with 0-1 MDR risk factorMDR risk factor

(n = 151)(n = 151)

PP value value

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 HCAP30-day Mortality in CAP versus HCAP

Definitions of CAP and HCAP Guideline Definitions of CAP and HCAP Guideline Concordant Therapy (not ICU patients)Concordant Therapy (not ICU patients)Definitions of CAP and HCAP Guideline Definitions 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 ill2 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 failure51 (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 received 1 2408 received GC-HCAP GC-HCAP

therapy (76.7%)therapy (76.7%)

1 211 received 1 211 received GC-HCAP GC-HCAP

therapy (8.0%)therapy (8.0%)

2 452 received 2 452 received non-GC therapy non-GC therapy

(16.3%)(16.3%)


Guideline Concordant Therapy and HCAPGuideline Concordant Therapy and HCAPGuideline Concordant Therapy and HCAPGuideline Concordant Therapy and HCAP

Overall Health OutcomesOverall 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

4040

3535

3030

2525

2020

1515

1010

55

00

Bac

teria

l pat

hoge

ns (

%)

Bac

teria

l pat

hoge

ns (

%)

S. pneumoniaeS. pneumoniae S. aureusS. aureus PseudomonasPseudomonas

1 risk factor, n=10451 risk factor, n=1045 2 risk factors, n=3032 risk factors, n=303 ≥3 risk factors, n=42≥3 risk factors, n=42

Bacterial Pathogens in Culture-positive HCAPBacterial Pathogens in Culture-positive HCAP


P<0.001

P<0.001

P=0.39

3535

3030

2020

2525

1515

1010

55

00

Mor

talit

y (%

)M

orta

lity

(%)

30-day30-day 90-day90-day

1 risk factor, n=116731 risk factor, n=11673

2 risk factors, n=30792 risk factors, n=3079

≥3 risk factors, n=319≥3 risk factors, n=319

30-day and 90-day Mortality in HCAP30-day and 90-day Mortality in HCAP


P<0.001

P<0.001

Characteristics of the Included StudiesCharacteristics of the Included StudiesCharcteristicsCharcteristics

TotalTotal

DesignDesign

ProspectiveProspective

RetrospectiveRetrospective

Definition of HCAPDefinition of HCAP

ATATS/DSA definitionS/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 ManagementApproach 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 secretionsLeak around ETT cuffLeak around ETT cuff

ETT BiofilmETT Biofilm

Host lung defensesHost lung defensesBacterial pathogensBacterial pathogens

ColonizationColonization

VATVAT

VAPVAP

Craven DE et al. Clin Infect Dis 2010; 51: S59-S66

VAP Rates in Selected CountriesVAP Rates in Selected CountriesVAP Rates in Selected CountriesVAP Rates in Selected Countries

20

18

16

14

12

10

Mea

n V

AP

s pe

r 10

00 v

entil

ator

day

s

6

4

2

0

8

USA Med

ical

USA Sur

gica

l

Italy

Austri

aSco

tland

Franc

eSpa

inBel

gium

INIC

C

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

0.02004 2005 2006 2007 2008 2009

1500

2000

1000

2500

3000

500

0

VA

P c

ases

per

100

0 ve

ntila

tor

days

Num

ber

of

hosp

ital r

epor

ting

to C

DC

Surgical ICUs

Medical ICUs

Mean VAP rate


VAP Rates in the USAVAP Rates in the USAVAP 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 the Two of the followingfollowing

New or progressive and persistent infiltrate

One of the One of the followingfollowing

Two or more serial Two or more serial radiographs with at least radiographs 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 soundsFor 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 VAPCDC Clinical Definition for VAPCDC Clinical Definition for VAP

Fever (>38°C or >100.4oF)

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

012

01

FewModerateLargePurulent

Tracheal secretions 012

+1

> 240 or presence of ARDS≤ 240 or absence of ARDS

Oxygenation Pao2/Fio2,mm Mg

02

No infiltratePatchy or diffuse infiltrateLocalised infiltrate

Chest radiograph 012

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 evaluation14

Detailed evaluation14

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 irrelevant10

Excluded irrelevant10

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

Fábregas

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

Fábregas

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

Fábregas

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 ModelPooled 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

0.011 100.0

Diagnostic odds ratio


VAE Definition Algorithm SummaryVAE 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 meet Did not meet criteriacriterian=39n=39



EnrolledEnrolledn=10n=10



SurvivorsSurvivorsn=2n=2

NonsurvivorsNonsurvivorsn=10n=10


NonsurvivorsNonsurvivorsn=6n=6


Nonsurvivors2nNonsurvivors2n=2=2

SepsisSepsisn=259n=259

Respiratory ICURespiratory ICUn=82n=82

Surgical ICUSurgical ICUn=91n=91

Emergency ICUEmergency ICUn=86n=86

VAPVAPn=12n=12

Non-VAPNon-VAPn=31n=31

VAPVAPn=15n=15


VAPVAPn=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

0.00.2 0.4 0.6 0.8 1.00.0

Sen

sitiv

ity 0.6

1-Specificity

0.2 0.4 0.6 0.8 1.00.0

1-Specificity

CPIS WBC

sTREM-1PCT

Ref linesTREM-1 + CPIS

sTREM-1 + WBCRef line

A B

Diagnostic Value in VAPDiagnostic Value in VAPDiagnostic Value in VAPDiagnostic Value in VAP


1.0

0.8S

ensi

tivity

0.2 0.4 0.6 0.8 1.0

1-Specificity

0.6

0.4

0.2

0.00.0

PCT + CPIS

CPISPCT

Ref line

Prognostic Value in VAPPrognostic Value in VAPPrognostic Value in VAPPrognostic Value in VAP


Initial Empirical Therapy for VAPInitial Empirical Therapy for VAPInitial Empirical Therapy for VAPInitial Empirical Therapy for VAP

CeftriaxoneCeftriaxoneororLevofloxacin, moxifloxacin or Levofloxacin, moxifloxacin or ciprofloxacinciprofloxacinororAmpicillin/sulbactamAmpicillin/sulbactamororEtrapenemEtrapenem

Antipseudomonal cephalosporin (cefepime, ceftazidime)orAntipseudomonal carbepenem (imipenem or meropenem)orβ-lactam/β-lactamase inhibitor (piperacillin-tazobactam)plusAntipseudomonal fluroquinolone (ciprofloxacin or levofloxacin)orAminoglycoside (amikacin, gentamicin or tobramyicin)plusLinezolid 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 TherapyNo. 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(M-H, Random, 95% CI)

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(M-H, Random, 95% CI)

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(IV, Random, 95% CI)

-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(IV, Random, 95% CI)

-0.01 (-0.57, 0.55)

28-day mechanical ventilation-free days

2 431 Mean Difference(IV, Random, 95% CI)

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 VAPPharmacologic-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 VAPNon-pharmacologic-based strategies for prevention of VAPNon-pharmacologic-based strategies for prevention of VAP

StrategyStrategy RecommendationRecommendation Evidence levelEvidence level

Non-invasive mask ventilationAvoid re-intubationAvoid patient transportsOrotracheal intubation preferredOrogastric intubation preferredEarly tracheostomyRoutine ventilator circuit changesHeat-moisture exchangerClosed endotracheal suctioningSubglottic secretion drainageShorter duration mechanical-ventilationAdequate ICU staffingSilver-coated endotracheal tubePolyurethane endotracheal tube cuffSemi-erect positioningRotational bedsChest physiotherapyUse of protocols/bundles

YesYesYesYesYesNoNoYesYesYesYesYesYesYesYesYesNoYes

122121111112111112

Kollef MH. Surgical Infections 2011; 12: 211-220

Health & Medicine

Pneumonia Phenotypes by Feldman