Ventilator-associated pneumonia

Course content

Course roadmap
Basic concepts

Common infections

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 “Antimicrobial resistance, as I say
again and again, is a slow-motion
tsunami. It is a global crisis that
Dr. Margaret Chan
must be managed with the utmost
urgency.”
New York
April 18, 2016

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 Core Competencies
Core competencies for
antimicrobial prescribing
C1: Understands the patient and the patient’s clinical needs
C2: Understands treatment options and how they support the
patient’s clinical needs
C3: Works in partnership with the patient and other healthcare
professionals to develop and implement a treatment plan
C4: Communicates the treatment plan and its rationale clearly to
the patient and other health professionals
C5: Monitors and reviews the patient’s response to treatment

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 Objectives
• Understand how the emergence of antimicrobial resistance in
a particular hospital jeopardizes patients with nosocomial
infections, like ventilator-associated pneumonia
• Illustrate the importance of obtaining appropriate specimens
for culture and using these results to optimize the use of
antibiotics.
• Emphasize the appropriate duration of therapy for ventilator
associated pneumonia

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Ventilator-associated pneumonia (VAP)

• Among the most

common hospital-
acquired conditions
• Associated with longer
hospitalizations and
intense resource
utilization

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 Epidemiology of VAP
• Distinct from
community-acquired
pneumonia

• Hospitalized patients
often colonized with
nosocomial pathogens

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A hospital’s microbial ecology
Several factors contribute
including:
• Patient population
• Intensity of antibiotic
use
• Infection control
precautions

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 Core Competencies 1, 2, 3, 4

Case 1

Diagnostic
work-up
Clinical
Clinical Therapeutic re-assessment Modify
assessment decisions antimicrobials
Data
Patient review
education
Initial evaluation Subsequent evaluation

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65 year-old female ICU patient with:

congestive heart failure

developed respiratory failure

requiring mechanical ventilation

developed renal insufficiency

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65 year-old female ICU patient who:
On hospital day #4, developed fever

increased suctioning requirements

increased oxygenation requiremnts

diffuse rhonchi
chest x-ray with new right lower lobe
infiltrate

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 Core Competencies 1 & 2

Drug Patient
Severity Source Cultures
resistance factors

Optimal antibiotics

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 How severe is the patient’s condition?

Drug Patient
Severity Source Cultures
resistance factors

Severe - need start empiric

therapy soon

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 What is the likely source & pathogens?

Drug Patient
Severity Source Cultures
resistance factors

• Clinical picture consistent with VAP

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 What is the likely source & pathogens?

Drug Patient
Severity Source Cultures
resistance factors

• Clinical picture consistent with VAP

• Most common organisms: S. aureus &
• gram-negative organisms

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 How likely is resistance?

Drug Patient
Severity Source Cultures
resistance factors

• Varies by institution
• Cumulative antibiograms can help

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 How likely is resistance?
2016 American guidelines
Risk factors for infection due to MDROs:
Drug Patient
Severity • Intravenous
Source antibiotics
resistance
within 90 days
factors
Cultures
• Septic shock at time of VAP diagnosis
• Acute respiratory distress syndrome
• Renal replacement therapy prior to
VAP

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 How likely is resistance?
2016 American guidelines
Consider empiric therapy directed at
methicillin Drug Patient
Severity Source resistant Staphylococcus Cultures
resistance
aureus (MRSA) if: factors
• Patient received intravenous antibiotics
within 90 days
• Prevalence of MRSA in your hospital
>10 – 20%

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 How likely is resistance?
2016 American guidelines
Consider empiric therapy directed at MDR
gram-negative Drug
pathogens if: Patient
Severity Source Cultures
resistance factors
• Prevalence of resistance among gram-
negative pathogens in your hospital
>10 % or unknowns

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 Other considerations?

Drug Patient
Severity Source Cultures
resistance factors

• Dosing medication
in ICU challenging

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 Do I need cultures?

Drug Patient
Severity Source Cultures
resistance factors

• Blood cultures
• Respiratory
cultures

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 Core Competencies 1 & 2

Return to case

Diagnostic
work-up
Clinical
Clinical Therapeutic re-assessment Modify
assessment decisions antimicrobials
Data
Patient review
education
Initial evaluation Subsequent evaluation

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 Core Competencies 1 & 2

Empiric choice

Drug Patient
Severity Source Cultures
resistance factors

Vancomycin
Piperacillin/tazobactam + levofloxacin

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 Core Competencies 1, 2, 4 & 5

Return to case

Diagnostic
work-up
Clinical
Clinical Therapeutic re-assessment Modify
assessment decisions antimicrobials
Data
Patient review
education
Initial evaluation Subsequent evaluation

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48 hours after initiation of antibiotics…

less suctioning requirements

decreased ventilator support

requirements

afebrile for last 24 hours

blood cultures without growth

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48 hours after initiation of antibiotics…

• Endotracheal aspirate culture:

Pseudomonas aeruginosa
– Susceptible to cefepime,
piperacillin-tazobactam,
aminoglycosides
– Resistant to
fluoroquinolones

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 Core Competencies 1, 2, 4, 5

An informed re-evaluation

Review Evaluate
Check for
micro- Assess route &
adverse
biologic spectrum duration of
effects
data therapy

Optimal antibiotics

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Does the microbiologic data make sense?

Review Evaluate
Check for
micro- Assess route &
adverse
biologic spectrum duration of
effects
data therapy

Yes. Pseudomonas aeruginosa is a

common cause of VAP

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Does the microbiologic data make sense?

• Some cultures obtained

through endotracheal
tubes represent
colonization instead of
infection.

WHO/A. Kristensen

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Verify the spectrum of therapy

Review Evaluate
Check for
micro- Assess route &
adverse
biologic spectrum duration of
effects
data therapy

MRSA not isolated in culture

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Verify the spectrum of therapy

Review Evaluate
Check for
micro- Assess route &
adverse
biologic spectrum duration of
effects
data therapy

De-escalation:
Anti-bacterials to target
Pseudomonas isolated in culture

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Unintended consequences?

Review Evaluate
Check for
micro- Assess route &
adverse
biologic spectrum duration of
effects
data therapy

Stable renal function

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How long and by which route?

Review Evaluate
Check for
micro- Assess route &
adverse
biologic spectrum duration of
effects
data therapy

7 days for most

patients with VAP

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How long and by which route?

Durations tailored to
Review individual patients Evaluate
Check for
micro- Assess route &
adverse
biologic spectrum duration of
Consider use of effects
data therapy
procalcitonin if
available

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Prevention of VAP
Interventions include:
• Minimizing sedation
• Assessing for extubation
readiness
• Minimizing pooling of
secretions
• Elevating head of bed

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Review: Ventilator-associated pneumonia
Drug

prescription
Dose .............
.............
Route
.............

Duration

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Review: Ventilator-associated pneumonia
Drug
Obtain cultures in all patients
with probable VAP prior to
starting empiric antibacterials. prescription
Dose .............
.............
Route
.............

Duration

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Review: Ventilator-associated pneumonia
Drug
Access to institutional cumulative
antibiogram can inform empiric
antimicrobial decisions. prescription
Dose .............
.............
Route
.............

Duration

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Review: Ventilator-associated pneumonia
Drug
Commit to reassessing
antimicrobial therapy in response
to microbiologic and clinical data prescription
Dose .............
.............
Route
.............

Duration

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Review: Ventilator-associated pneumonia
Drug
Recommended duration of
therapy for VAP is 7 days.
prescription
Treatment courses should be Dose .............
.............
Route
tailored to individual patients. .............

Duration

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