VENTILATOR

ASSOCIATED
PNEUMONIA

DR IMRAN GAFOOR
DR DEBASHISH DHAR
DEPTT OF CRITICAL CARE &
EMERGENCY MEDICINE
SIR GANGARAM HOSPITAL

DEFINITIONS

VAP : ventilator associated pneumonia is

a
nosocomial pneumonia which
develops in ICU patients who have been
tracheally intubated/MV 2 days.
VAT : ventilator associated
tracheobronchitis,
in volume & purulence of resp
secretions,fever
leucocytosis but no radiological
infiltrates.

HCAP : health care associated pneumonia.

RISK FACTORS
- hospitalzn. For 2 days within preceding
90 days,
- residencein nursing home or extended
care facility,
- home infusion therapy (antibiotics)
- chronic dialysis within 30 days,
- home wound care
- family member with MDR pathogens

OTHER CLASSIFICATION :
PRIMARY ENDOGENOUS PNEUMONIA
causative micro-organisms are isolated in surveillance cultures on admission.
SECONDARY ENDOGENOUS PNEUMONIAcausative micro-organisms later on colonize
oropharynx/GIT & reach lower resp tract
EXOGENOUS PNEUMONIA
pt is not a previous carrier but colonised by
ventilator tubes ,bronchoscopes,humidifiers etc.

EARLY vs LATE ONSET VAP :

EARLY ONSET (<4 days)
antibiotic sensitive,better
prognosis
LATE ONSET (5 days or more)
MDR pathogens,increased
There
mortality
were no significant differences in the prevalence of

potential MDR pathogens associated with early-onset or

late-onset VAP, even in subjects with prior antibiotics.
Empiric therapy for early-onset VAP should also include
agents likely to be effective for potential MDR pathogens.

Respir Care. 2013

TROVILLET et al found that two variables were

significant for predicting infection with MDR
VAP :
- mechanical ventilation 7 days
- prior antibiotic use esp broad spectrum
EPIDEMIOLOGY :
second most common nosocomial infection
but leading cause of attributable mortality
(33-50%)

INCIDENCE IN INDIA :

Incidence of HAP in india is 53.9%.

Incidence of VAP in india is 8.95/1000

ventilator days.

Mortality rate(attributable) is 37% 47.3%

Park Es et al Am j inf
control(2000)

VAP IN SGRH ICU

(2012)
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It is estimated that 9-27% of patient

undergoing
MV for > 2 days are affected by VAP.
. Cook et al demonstrated that,risk of VAP is 3%
on first 5 days of MV,2% from 5-10 days,& 1%
for remaining days.
MORTALITY : Several cross matching studies
have estimated that one third to half of all VAP
related deaths are result of
pseudomonas/acinetobacter pneumonia with
bacteremia.
- mortality is inversely related to adequacy
of initial empirical thereapy.

- Correct & prompt treatment of

pneumonia results in better patient
survival.
- Inappropriate therapy is strongly
associated with worse survival.
PATHOGENESIS :
* Pulmonary aspiration of
colonised (whether endo/exogenous)
oropharyngeal secretions across
tracheal tube cuff is the main
pathogenic mechanism for
development of VAP.

* Tracheal intubation is the conditio sine

qua non for development of pneumonia
because it
facilitates aspiration of pathogens &
hinders
intrinsic respiratory defenses.
* Normally ETT has HVLP cuff,the
potential diameter of which is two to three
times larger than tracheal
diameter,so,when tracheal cuff
is inflated within trachea,folds invaraibly
form along cuff surface,causing consistent
micro/macro aspiration of oropharyngeal
secretions.

* ETT is commonly made of PVC &

bacteria easily adhere to its internal
surface forming a complex structure called
BIOFILM (sessile
bacteria embedded within a self
produced
exopolysaccharide matrix)
* ETT biofilm is difficult to eradicate &
constitutes a persistent source of
colonization.
SOURCES OF COLONIZATION :
- hands of ICU staff
- colonised bronchoscopes

- respiratory equipments
- humidifiers
- ventilator temp sensors
- nebulizers
- contaminated environment.
- In critically ill patients endogenous oral
flora shifts early to aerobic gram
pathogens (pseudomonas,MRSA),pulmonary aspiration
of
which leads to pneumonia.

* Azarpazhooh et al showed that

improved oral
hygiene & frequent professional oral
health
care reduces progression or occurrence
of
respiratory infection among patients in
ICU.
* Orotracheal as compared to
nasotracheal intubation is associated with a decreased
incidence
of sinusitis & thus VAP.
IMPAIREMENT OF RESPIRATORY

- no protection from epiglottis

- cough not possible
- tracheally intubated patients have very
low muco ciliary velocity (0.81.4mm/min)
higher risk for pulmonary complication.
- Temporary immunoparalysis during
early
course of ICU stay (low levels of HLADR
expression on monocytes),may
predispose to
colonization.

ETIOLOGIC AGENTS :
* VAP is commonly caused by aerobic gram
bacilli(peudomonos,E.coli,klebsiella,acinetobacter),while S.AUREUS is predominant
gram + organism.
EPIC-II study confirmed that pseudomonos &
staph aureus are most common isolated pathogens in ICU.
UNDERLYING DISEASES :
- patients with COPD have higher risk for H.infl,
moraxella,pseudomonos,pneumococcus,
aspergillus

In a study of nosocomial pneumonia in 51

ICU patients in india,the most commonly
isolated organisms were
P.auroginosa(20%), Acinetobacter spp
(38%),klebsiella(23%),
MRSA(5%).
The
data also clearly demonstrate that the incidence
and prevalence of multidrug-resistant pathogens are
rising in Asian countries. A. baumannii
calcoaceticus
complex is emerging as a major pathogen in
most of
the ICUs in these countries. MRSA, although present,
is not as big a problem doi:10.1016/j.ajic.2007.05.
as in the Western world;
011

Candida & aspergillus are m/c isolated fungi

in
immunocompromised.
Recent reviews show that candida in
respiratory samples demonstrate only
colonosation rather than pneumonia.
Viruses causing VAP : HSV-I,CMV
PREVENTIVE STRATEGIES FOR
NOSOCOMIAL PNEUMONIA :
1) Implementation ,as VAP bundle,of nosocomial pneumonia preventive strategies
that have proven efficacy in reducing morbidity & mortality.

2) Implementation of education
programmes
(respiratory care physicians & nurses
being
primary recepients),& frequent
performance feedbacks & compliance
assesment.
3) Strict alcohol based hand hygiene.
4) Avoidance of tracheal intubation & use of
NIV
when indicated(acute exacebn. of COPD,
acute hypoxemic resp
failure,immunocomp.
with pulmonary infiltrates)

5) Daily sedation vacation & implementation of

weaning protocols.
6) No ventilatory circuit tube changes unless
soiled or damaged.
7) Use of tracheal tubes with cuff made of novel
materials(polyurethane; & LVLP cuffs made of
silicone &latex) & shape(conical)
8)Application of low level PEEP(5-8cm
H2O)during tracheal intubation.
9) Use of silver coated ETT
NASCENT trial concluded that silver coated
ETT has incidence of VAP, mortality in
pts
with VAP,is cost effective & has greatest
impact during first 10 days.

10) Aspiration of subglottic secretions(every

4-6hrs)
11) Internal cuff pressure maintained within
25-30
cm H2O & carefully controlled during
transport of patients outside ICU.
12) Earlier tracheostomised pts (mean~7
days)
had shorter length of M/V & ICU stay,a
trend
towards pneumonia but no survival
benefit as
compared to late
tracheostomy(mean~14 days)

14) Intubated pts should be kept in semirecumbent position(30-45),rather than

supine to prevent aspiration;especially
when enterally fed.
15) Continuous lateral rotation of bed helps
to reduce extravascular lung
water,improveV/Q
& enhance mobilization of secretions.
16) Post pyloric feeding in patients with
impaired gastric emptying
17) Risk of VAP associated with early
enteral feeding didn`t translate into
risk of death,so,early enteral feeding
advised.

18) Stress ulcer prophylaxis in high risk

pts(coagulopathy, duration of M/V,h/o
GI bleed.
19) Oral care with 2% chlorhexidine.
20) SELECTIVE CONTANINATION OF DIGESTIVE
TRACT (SDD) :
- consists of nonabsorbable antibio. Against
gram (tobramycin.polymyxin E) + nystatin/
ampho B for candida administered into GI to
prevent oropharyngeal & gastric colonization.
- SDD reduces incidence of VAP & its the only
strategy that has shown survival benefit

SDD may promote growth of MRSA &

enterococcus,so,its highly recommended
to
conduct appropriate surveillance of
antibiotic resistance pattern.
21) Use of probiotics is promising but
additional
evidence required.
DIAGNOSIS :
- fever,tachycardia,leucocytosis too
nonspecific
- tachypnea & consolidation more
specific
- in elderly & immunocomp. Lethargy &

An imaginary vertical line from the sternal

notch to the mouth, passing through the
middle of the trachea should be used as a
surface landmark in order to identify an
orientation that could prevent
aspiration of oropharyngeal contents across
the
cuff and improve drainage of airway
- Lateral slight-Trendelenburg position
scretions.
achieved with
the bed tilted few degrees below horizontal

Current Opinion
in Critical Care
2011,
17:5763

Chest x rays : difficult to

interpret,limited technical quality,misses
subtle lung infiltrates.
D/d for infiltrates :
- cardio/non cardiogenic pulmo.
Edema
- atelectasis
- pulmonary contusions
- no radiographic sign has d/g accuracy of
>68%
Air bronchograms or alveolar opacities in
pts without ARDS co-related well with
pneumonia.
Pleural effusion seen with

diarrhea/abdominal pain legionella p.

Otitis media /pharyngitis M.pneumonia
Herpes labialis pneumococcal
Ecthyma gangrenosum pseudomonos
septicemia
NOTE : >30 bpm & Na < 130 during
admission predict poor outcome.
CAVITATIONS :
- multiple cavitory nodules rt sided
endocarditis
- rapid gram () pneumonia
- subacute anaerobic/mycobacterial
chronic carcinoma,lymphoma,wegners
granulomatosis

CLINICAL PULMONARY INFECTION SCORE

(CPIS) :
CRITERION
0
1
2
tracheal secn.
(-)
not purulent
purulent
x- ray infiltrates
NO
DIFFUSE
LOCALISED
temp C
36.5&38.4 38.5&38.9
39or36
leucocytes 4000&11000 <4000or>11000
+immature
neutro>50% PaO2/FiO2
240,noARDS

>240 or ARDS

CPIS 6 is regarded as threshold for

pneumonia but value remains to be
validated.
QUANTITATIVE CULTURES OF
ENDOTRACHEAL ASPIRATES MAY
HAVE AN ACCEPTABLE DIAGNOSTIC
ACCURACY.
Current d/g threshold for tracheal
aspirates is
10-10^
CFU/ml

contaminants is
10
CFU/ml

- NON INFECTIOUS CAUSES OF

FEVER/INFILTRATES MIMICKING
NOSOCOMIAL PNEUMONIA :
- chemical pneumonitis
- atelectasis
- pulm embolism
- ARDS
- pulmomary hemorrhage
- lung contusion
- infiltrative tumour
- radiation pneumonitis
- drug reaction
- BOOP

MOST RECENT IMPROVEMENTS IN D/G

:
* direct antibiogram using E test strips
applied directly to resp samples have
proved to be reliable,effective &
anticipate susceptibility by
48 hrs
* q PCR for mecA gene - for MRSA
pneumonia

Diagnostic strategies for hospital

acquired pneumonia :
- new or progressive chest infiltrate +
atleast 2 of
3 clinical criteria(fever>38c,leucocytosis
or leucopenia,purulent secretions)
represent beginning of diagnostic
procedures
clinical,non invasive semiquantative
strategy
major drawback is high sensitivity of
semi quantative culture results which
leads to over estimation of incidence of
nosocomial pneumonia.

 Invasive

and quantitative culturing

strategy for VAP :

- strongly recommended that d/g sampling

of
respiratory tract be obtained before
starting
any new antibiotic or
changing previous
antimicrobial
therapy.

PRACTICAL IMPLEMENTATION OF
A DIAGNOSTIC STRATEGY

STEP I : pt admitted/intubated for> 2

days,with no evident alternative foci of
infection with atleast 2 of 3 criteria :- fever > 37.8c or hypothermia <
36c
- TLC >12000/l or <4000/l
- purulent respiratory secretions

with new infiltrates in chest x ray :

if yes(NP/VAP)||| if no (VAT)

STEP II : before initiating new empirical

antibiotics ,collect sample as follows :a) expectoration
b) tracheo-bronchial aspirate
c) BAL or mini BAL
d) PBS
- 2 blood cultures
- pleural fluid sample for parapneumonic
effusion
- legionella/pneumococcal antigens in
urine
- CBC/electrolytes/RFT/LFT/procal/ABG/
CRP

STEP III : calculate CPIS (TO IMPROVE

OBJECTIVE ASSESMENT OF CLINICAL
PARAMETERS)

TREATMENT :most frequently isolated organisms are

s.aureus,pseudomonos f/b
enterobacteriacea(e
coli,klebsiella,enterobacter) then gram as
acinetobacter,stenotrophomonas,burkhold
heria & lastly h influenzae,pneumococcus.
selection of antimicrobial tailored to
local prevelance of pathogens &
antimicrobial patterns of resistance.

DYNAMICS OF CHANGE OF ORAL

FLORA
1) Healthy subjects pneumococcus,N menin.,
strepto pyogenes
2) acute/chronic
copneumococc,H.influen,enterobac.
morbidities
MSSA
3) 2 + antibiotics forESBL+
enterobac.,pseudomonos
3-5 days
MRSA
4) 3 + antibiotics for3 + non fermenting MDR
GNB
7 days

Choice of empiric anti

microbials

ATS/IDSA recommendations
t/t based on timing of onset & risk
factors for MDR pathogens

Risk Factors for Multidrug-Resistant

Pathogens
Antimicrobial therapy in preceding 90 days
Current hospitalization of at least 5 days
High frequency of antibiotic resistance in the community
or in the specific hospital unit.

Presence of risk factors for HCAP:

Hospitalization for at least 2 days in the preceding 90

days
Residence in a nursing home or extended care facility
Home infusion therapy (including antibiotics)
Chronic dialysis within 30 days
Home wound care
Family member with infection involving MDR pathogen
Immunosuppressive disease and/or therapy

Initial Intravenous Adult doses of Antibiotics

Niederman M. et al, AJRCCM, 2005 Antibiotics
Dosage*

Antipseudomonal cephalosporin

Cefepime 1-2g every 8-12h

Ceftazidime 2g every 8h

Carbapenems

Imipenem 500mg every 6h or 1g every 8h

Meropenem 1g every 8h

-Lactam/ -lactamase inhibitor

Piperacillin-tazobactam 4.5g every 6h

Aminoglycosides

Gentamicin 5-7mg/kg per d

Tobramycin 7mg/kg per d
Amikacin 20mg/kg per d

Antipseudomonal quinolones

Levofloxacin750mg every d
Ciprofloxacin 400mg every 8h
Vancomycin 15mg/kg every 12hs
Linezolid 600mg every 12h

NOTE : for legionella azithro +

cipro/levoflox
For resistant acineto carbapenem or
colistin +
tigecycline
Nebulised colistin/tobramycin are used
as adjunct to systemic antibiotics in severe
gram pneumonia,or,resistant bug
eliminated only by high level local drug
conc.
DURATION OF T/T :- majority of infections can be treated by
8 days course,for non fermenting gram( )
14 days
- prolonged t/t is required in :

Tissue necrosis,abscess,empyema

persistence of original
infection(perforation,
endocarditis)
FAVOURABLE CLINICAL COURSE :- defervescence
- improved PaO2/FiO2
- CRP in 3-5 days
- third day CPIS < 6

PREVENTIVE APPROACHES TO
VAP
- have focussed on cross
transmission,pulm.
aspiration across ETT cuff, bacterial
load in oropharynx.
HIGHLY EFFECTIVE INTERVENTIONS :
1. SEMIRECUMBENT POSITION
2. SEDATION VACATION
3. DAILY ORAL CLEANSING WITH 2%
CHLORHEXIDINE
4. SUBGLOTTIC SECRETION DRAINAGE

FERRER M (clinical infectious d/e

2010) :
- first study that validates 2005 ATS/IDSA
guidelines
- the study demonstrated worse microbial
prediction of 2005 guidelines,in comparison
to previous guidelines,in pts considerd at
low risk
for acquiring MDR pathogens & similar low
prediction for fungi.

Rather than focusing on VAP,

the new surveillance definition algorithm
for
adults broadens the surveillance
spectrum to
ventilator associated events(VAE)
A ventilator-associated
condition
(VAC) is identified if, after a 2-day period
of
stability or improvement on the ventilator,
the patient develops worsening
oxygenation
(specific increases in levels of FIO2 or PEEP
over two or more calender years)

Infection related ventilator-associated

complication (IVAC) is identified in pts with
VAC who meet 2 additional criteria of clinical
signs of infection (specifically, defined values
for an abnormal temperature or white
count) and antibiotics prescribed for atleast
4 days. Identification of possible & probable
VAP within IVAC patients is determined by
purulent respiratory secretions and/or
specific laboratory and diagnostic tests. The
new algorithm remains complex and the
CDC is developing additional guidance
for its implementation

Several features of the new VAE definition are

important. First, chest radiographs, a
required component in the current definition
of VAP,
are no longer used in the definitions of
VAEs (including VAP).Second patients who
are receiving rescue ventilation are excluded.
Third patients must have a period of at
least 2 days of stability or improvent on
mechanical ventilation prior to
worsening.fourth,
VAC (and by extension, IVAC and VAP) is
limited to patients who have have
been mechanically ventilated for atleast
3 calendar days

The VAP Surveillance Definition Working

Group
recommended removing chest
radiography from
the surveillance definition entirely.
The CDC NHSN definition of VAP (and now
VAE, VAC, and IVAC) was developed to enable
surveillance of an important event; the CDC
specifically states that it should not be
used for clinical diagnosis.

AMERICAN JOURNAL OF CRITICAL

CARE, September 2012, Volume 21,
No. 5

VENTILATOR ASSOCIATED CONDITIONS :pt on mechanical ventilation > 2 days

baseline period of stability or

improvement,followed
by sustained period of worsening
oxygenation

VENTILATOR ASSOCIATED CONDITION(VAC)

general objective evidence of

inflammation/infection

INFECTION RELATED VENTILATOR

positive results of microbiological/laboratory

testing

possible or probable VAP

April 2013 CDC/NHSN
Protocol