ICU Nosocomial

Pneumonia
Beth Stuebing, MD, MPH
Outline
• Epidemiology

• Diagnosis – clinical findings

• Diagnosis – attaining specimen

• Treatment

• Complications

• Prevention
Epidemiology
• Ventilator associated pneumonia (VAP) is
the most common and deadliest hospital
acquired infection in the ICU
• 10-20% of pts vented >48hrs
• 2x-10x the mortality of pts without VAP
• Although some studies argue no
difference in mortality
• VAP with Pseudomonas ~40% mortality
• Treatment of pneumonia accounts for ½ of
antibiotic use in the ICU
Risk Factors, Pathogenesis
• Just being intubated! Each vented day increases
VAP rate 1-3%

• Aspiration of oral pathogens around cuff

• Aspiration of GI contents

• Biofilm within ET tube

• Equipment and personnel contamination

• Hematogenous spread from another source

Patient Related Risk Factors
• Suppressed immune system from frequent
• blood transfusion (>4 units)
• antibiotics
• inhaled steroids
• Sedated, paralyzed patients unable to
clear secretions
• Chronic disease, ex. Renal failure, DM
• Tobacco use
• Antacids, H2 blockers
The Culprits
• Early (<5 days, mortality 22%)
• Strep pneumoniae, Staph aureus,
sensitive GNR
• Late (>5 days, mortality 47%)
• MRSA
• Pseudomonas in 10-20%
• Resistant GNR (Acinetobacter,
Klebsiella, E coli, Enterobacter)
• 50% is polymicrobial
Diagnosis – Clinical Findings
• Difficult, complex, and frequently debated,
because:
• Overtreatment is BAD
• Undertreatment is WORSE
• Sensitivity of VAP clinical diagnosis 58-
83% with infiltrates on CXR
• Post mortem exam of those suspected of
having VAP showed true incidence 30-
40%
 CPIS
• Guide for when to get a specimen
 Infiltrates: not always straight forward

• Pneumonia accounts for only 1/3 of infiltrates in ICU pts

 Diagnosis – attaining specimen
• Deep tracheal aspirate not appropriate –
contaminated with airway colonizing
organisms

• Blind or bronchoscopy?
• Clinical diagnosis without scope: 15-70%
false positive rate – inappropriate abx
use, cost, false sense of security
• Large French study: invasive diagnosis
had decreased mortality, organ
dysfunction, and antibiotic use
• Other studies show no difference
• Bronchoscopy is expensive, needs
expertise, may delay initiating treatment
Diagnosis: attaining specimen
• Bronchoalveolar lavage or protected specimen
brush?

• Qualitative or quantitative culture?

• Quantitative cultures are standard of care

• Routine “surveillance” cultures are NOT advised,

and rarely identify the pathogen of VAP that
evolves later

• Presence of squamous cells, absence of

macrophages indicates upper airway secretions
instead of deep specimen
Protected Specimen Brush
• >10^3 colonies/mL indicative of lower
respiratory infection
• 66% sensitivity, 90% specific
Bronchoalveolar Lavage (BAL)
• >10^4 colonies/mL positive for infection
• Significant WBC with intracellular organisms,
no squamous cells
• Elevated LDH and IL1B in BAL may correlate
with presence of pneumonia
• 73% sensitive, 82% specific – most accurate
Future Directions in Diagnosis
• Measuring immunoglobulin-triggering
receptor expressed on myeloid cells
(sTREM-1)
• 98% sensitive and 90% specific for
pneumonia in one study of 148 patients

• Measuring procalcitonin – appears to rise

with bacterial pneumonia and worsening
sepsis
• May also be helpful as prognostic
indicator, even when to stop antibiotics
Treatment
• Empiric broad coverage for patients
considered truly infected
• New or worse infiltrate plus 2 of 3:
purulent sputum, fever, leukocytosis
• CPIS >6
• Know your ICU antibiogram
• Incorrect initial antiobiotics results in
increased morbidity, mortality, length of
stay, and cost
Antibiotic Choice
• Early -> limited spectrum
• Ceftriaxone, unasyn, augmentin,
fluoroquinolone
• Late, septic, prior hospitalization, h/o MDR
• Add MRSA coverage, pseudomonas
coverage (double coverage debatable)
• 48-72 hr reevaluation
• De-escalate according to culture
• Escalate for worsening, resistance
Duration of Antibiotics
• 6-8 days of appropriate coverage
• Extending >8 days of no benefit
• Some recommend adding aminoglycoside
for first 5-7 days
• Double coverage of Pseudomonas is
controversial – only shown benefit in 1
study in patients with bacteremia, not
pneumonia
Lack of Response
• Microbiologic response is faster than
clinical response
• Occult unrecognized source somewhere
else (in 50% of pts with VAP)
• Line, sinusitis, c diff, uti, empyema
• Repeat specimen with bronchoscopy may
be useful
• No survival benefit shown with lung biopsy
• Consider noninfectious causes: sarcoid,
vasculitis, hypersensitivity pneumonitis,
bronchiolitis obliterans organizing
pneumonia (BOOP), granulomatosis
 VAP suspected

Obtain sample

Empiric antibiotics

Day 2-3: reassess

Clinical improvement?

No Yes

Culture negative: Culture positive: Culture negative:

Look elsewhere Adjust therapy Consider stopping abx

Culture positive:
Narrow coverage
Complications
• Parapneumonic effusion
• Extrapulmonary infection
• Drug resistance
• Prolonged intubation
• Death!
Prevention
• Limit tubes, esp. nasal, avoid reintubation
• Adequately inflate ETT cuff
• Avoid over-sedation
• Daily spontaneous breathing trials
• Elevate head of bed at least 30 degrees
• Use noninvasive vent when possible
• Oral hygiene with antiseptic
• Early tracheostomy
• Healthcare staff hand hygiene
• Change circuit only when necessary
• Enteral feedings instead of parenteral
• Bolus vs continuous of debatable benefit
Questions ???