Managing Hospital Acquired Pneumonia / Ventilator Associated Pneumonia in the ICU

[0:12]Patient AH is an elderly woman with chronic lung and cardiac disease, admitted to the ICU following a stroke. On day six, AH developed a productive cough, decreased air entry bilateral and lethargy. Her O2 sat was 87% on 15 liters by face mask. She was febrile, short of breath, and her blood pressure had dropped. Her white count was elevated, and a chest X-ray showed a new infiltrate. Sputum and blood samples were sent, and AH was diagnosed with hospital-acquired pneumonia or hap. Hap is the second most common hospital-acquired infection and occurs anywhere in the hospital. In the ICU, intubated patients develop ventilator-associated pneumonia or VAP. Hap is defined as pneumonia that develops more than 48 hours after admission, while a diagnosis of VAP requires patients to have been mechanically ventilated for more than 48 hours at the time of infection onset. Like all pneumonia syndromes, the diagnosis is based on the appropriate constellation of clinical signs and symptoms and can mimic other syndromes like heart failure or pulmonary embolism. A scoring tool such as the Clinical Pulmonary Infection Score, CPIS, can aid in the diagnosis of HAP or VAP. And a score greater than six correlates with the presence of high bacterial counts in the lungs. It can be used to risk stratify patients and to guide both starting and stopping antibiotics. Once appropriate respiratory samples have been sent for culture, prompt initiation of appropriate empiric antibiotics is essential for good patient outcomes. The core bugs in hap or VAP are the usual respiratory culprits. Streptopneumo and H flu, plus stafforeus, and some Gram negative bugs like E coli, Enterobacter species, Klebsiella species and Proteus. To identify target bugs, guidelines place emphasis on the duration of time in hospital prior to the onset of infection. The longer the time in hospital, the greater the likelihood of colonization by hospital-associated bugs. There are risk factors for infection with more difficult to treat organisms such as Pseudomonas, MRSA and ESBLs. These risk factors include recent hospital admissions, antibiotic use, immunosuppression and known colonization with any of these organisms. Empiric therapy should target the core bugs and account for these risk factors. Combination therapy for a pseudomonas infection is common, but not supported by the literature. Only if you are worried about pseudomonas or other multi-drug resistant organisms, is it reasonable to start with empiric combination therapy? For most patients, a single antimicrobial is sufficient. Once you have a bug identified or if cultures remain negative at 48 hours, narrow or target therapy for the remaining treatment. Our patient, AH, was admitted from home for six days and she hasn't been on antibiotics during her admission. However, if she had been intubated since admission, she would be considered a VAP and at risk of infection with more difficult to treat bugs. Seven days of antibiotics should be sufficient to treat most cases of HAP and VAP. 14 days minimum is recommended to treat bacteria pneumonia. Key messages. Start antibiotics promptly. Target core bugs. Consider patient risk factors. Combination therapy should be tailored once culture results are available. And treat most patients for seven days. To learn more about managing HAP and VAP in the ICU, check out our website, www.antimicrobialstewardship.com. This video is a part of the Mount Sinai Hospital / University Health Network Antimicrobial Stewardship Program. Script by Linda Dresser, Pharm D, FCSHP, based on CAHO modules by Kevin Duplisea, Pharm D and Linda Dresser, in collaboration with the MSH / UHN ASP team, whiteboard animation by KRYSKI BIOMEDIA. Bring your message to life.