Professional Documents
Culture Documents
Pathophysiology
Aspiration of oropharyngeal organisms
Pneumonias Classification
CAP
HCAP HAP
HCAP VAP
6
Nosocomial Pneumonias
Hospital Acquired
Ventilator Acquired
Pathological classification
Lobar pneumonia
Interstitial pneumonia
Bronchopneumonia Multi-lobar pneumonia Cavitary pneumonia Necrotizing pneumonia Lung Abscess
Pathophysiology
TYPICAL Organisms
Streptococcus pneumoniae
Haemophilus influenza Streptococcus pyogenes
Klebsiella pneumoniae
Moraxella catarrhalis Staph aureus
Prevotella sp.
Pathophysiology
ATYPICAL Organsims
Mycoplasma pneumoniae
Chlamydia pneumoniae Chlaymida sp.
Legionella sp.
Respiratory viruses Others
Pathophysiology
10
Why Guidelines?
Evidence-based practice
Best outcome for patients Best use of resource Restricts idiosyncratic behaviour
Legal protection
Identify research needs
Atypical
Gradual & insidious onset Low grade fever Dry cough, No blood tinge Good GC Walking CAP Low mortality 1-2%; except in cases of Legionellosis Mycoplasma, Chlamydiae, Legionella, Ricketessiae, Viruses are causative
13
CAP Pathogenesis
Inhalation Aspiration
Hematogenous
14
Age Obesity; Exercise is protective Smoking, PVD Asthma, COPD Immuno-suppression, HIV Institutionalization, Old age homes etc Dementia
ID Clinics 1998;12:723. Am J Med 1994;96:313
S.pneumoniae H.influenza Chlamydia Legionella spp S.aureus Mycoplasma Gram Neg bacilli Viruses
17
Streptococcus pneumonia
(Pneumococcus)
Strep pneumo
19
Strep pneumo
Gram positive lancet-shaped, encapsulated diplococcus Most common cause of CAP Multiple serotypes
20
1000
800 # of cases 600 400 200
22
<5
5 to 17 18-24
25-44
45-64
>65
70
60 50 40 30 20 10 0 0 <4 0 5 to 14 0 15-24 2 25-44 5.7 45-64 >65
# of deaths
23
CAP Risk Factors for Mortality Age > 65 Bacteremia (for S. pneumoniae) S. aureus, MRSA , Pseudomonas
26
No Infiltrate
Infiltrate or Clinical evidence of CAP Evaluate need for Admission Out Patient PORT & CURB 65 Medical Ward
Alternate Dx.
ICU Adm.
27
Diagnosis of Pneumonia
100 80
PERCENT
28
Diagnostics
Labs
CBC
BMP
Imaging
CXR
CT scans
Cultures
Blood
Sputum
29
Other tests
30
Clinical Parameter Age in years For Men (Age in yrs) For Women (Age -10) NH Resident Co-morbid Illnesses Neoplasia Liver Disease CHF CVD Renal Disease (CKD)
Clinical Parameter
Clinical Findings
Altered Sensorium Respiratory Rate > 30 SBP < 90 mm Temp < 350 C or > 400 C Pulse > 125 per min Investigation Findings Arterial pH < 7.35
BUN > 30
Serum Na < 130 Hematocrit < 30% Blood Glucose > 250 Pa O2
20 points
20 points 10 points 10 points 10 points
Class II
70
Class III
71 90
Class IV
91 - 130
Class V
> 130
32
Outpatients
Hospitalised
Score
33
Class III
Class IV Class V
71 - 90
91 - 130 > 130
0.9 2.8
8.5 9.3 27 31.1
Brief hospitalization
Inpatient IP - ICU
34
CURB 65 Confusion BUN > 30 RR > 30 BP SBP <90 DBP <60 Age > 65
35
Algorithmic Approach
Step 4 Step 1
< 50 Years
Step 2
No Co-morbidity
Step 3
Class I
No CURB
Only OP
CURB +
CAP Patient
Co-morbidity Present
50 Years
PORT 36
Class III
Class IV and V
38
CHEST X RAY
40
Diagnostics: CXR
Findings
Infiltrates
Pleural effusions
Abscess/Cavities Bulging fissures
Atelectasis
Air bronchograms
Other findings
PTX
Pleural thickening/Scarring Pulmonary edema
41
Lymphadenopathy/Masses
Diagnostics: CXR
Normal CXR
Immunocompromised
Dehydrated
Early infection
42
Diagnostics: CXR
Respiratory Medicine May 2006: 100, 926-32
192 patients with pneumonia
Excellent IR for lobes involved, extent of infiltrate, pleural effusion Poor IR for pattern of infiltrate Minimal relation found between cultured pathogens and radiologic features of infiltrate on CXR
43
Diagnostics: CT scan
CT scan
Alternative diagnoses
Unresolved cases Complications suspected
Concerning CXR
Treatment failure
44
In addition to a constellation of suggestive clinical features, a demonstrable infiltrate by chest radiograph or other imaging technique, with or without supporting microbiological data, is required for the diagnosis of pneumonia.
Patients with CAP should be investigated for specific pathogens that would significantly alter standard (empirical management decisions, when the presence of such pathogens is suspected on the basis of clinical and epidemiologic clues
45
46
47
Diagnostics: Cultures
Sputum gram stain/culture
Change antibiotic therapy
Cost
Process issues
Sputum cultures?
Are sputum cultures useful in ED? Are sputum cultures useful in ICU? Do antibiotics affect yield of sputum?
48
Diagnostics: Cultures
Sputum cultures: Recommendations
Outpatient
Optional
Inpatient
Optional Recommended when result may change therapy
Recommended
ICU admission/Severe CAP
49
Severe COPD
57 % 97 %
82 % 99 %
95 %
71 %
93 %
96 %
50
RECOMMENDATIONS
Pretreatment Gram stain and culture of expectorated sputum should be performed only with a good-quality specimen. Patients with severe CAP, as defined above, should at least have blood samples drawn for culture, urinary antigen tests for Legionella pneumophila and S. pneumoniae performed, and expectorated sputum samples collected for culture.
The yield of sputum bacterial cultures is variable and strongly influenced by the quality of the entire process.
The yield of S. pneumoniae, for example, is only 40%50% from sputum cultures from patients with bacteremic pneumococcal pneumonia.
The yield of cultures is substantially higher with endotracheal aspirates, bronchoscopic sampling, or transthoracic needle aspirates although specimens obtained after initiation of antibiotic therapy are unreliable and must be interpreted carefully .
52
Diagnostics: Cultures
Blood Cultures
Yield pathogen 5-15%
53
Pretreatment blood cultures yielded positive results for a probable pathogen in 5%14% in large series of nonselected patients hospitalized with CAP.
The yield of blood cultures is, therefore, relatively low when management decisions are analyzed, the impact of positive blood cultures is minor.
54
The most common blood culture isolate in all CAP studies is S. pneumoniae.
Because this bacterial organism is always considered to be then most likely pathogen, positive blood culture results have not clearly led to better outcomes or improvements in antibiotic selection .
Blood cultures are also indicated when patients have a host defect in the ability to clear bacteremia
55
11% 16%
68%
56
1000
ns
100
CRP (mg/L)
10
0.1
2 CRB-65 score
57
P<0.0001
100
PCT (ng/mL)
10
0.1
0.01
0.001
2 CRB-65 score
58
K. pneumoniae S. aureus -
35.7 %
31.8 %
14.7 %
12.0 % 9.8 % 7.4 %
Outpatient Care
Hospital Admission
Ward
ICU
oral
i.v.
G. Hffken, J. Lorenz, W. Kern, T. Welte, T. Bauer, K. Dalhoff, E. Dietrich, S. Ewig, P. Gastmeier, B. Grabein, E. Halle, M. Kolditz, R. Marre, and H. Sitter. Guidelines of the Paul-Ehrlich-Society of Chemotherapy, the German Respiratory Diseases Society, the German Infectious Diseases Society and of the Competence Network CAPNETZ for the Management of Lower Respiratory Tract Infections and Community-acquired Pneumonia. Pneumologie 64 (3):149-154, 2010.
60
Placebo-controlled Study
61
Methods
39 g/day of M.& B. 693 2(p-Aminobenzenesulphonamido)pyridine Gram stain White blood cell count Clinical data
62
Mortality of CAP
p = 0,0004
63
Evans GM, Gaisford WF. Lancet 1938;14-19.
64
65
Objective 1
Objective 2
66
45
17
CAP
HAP
HAP on CAP
Kollef, et al. Chest 1999;115:462474
67
68
70
Fluroquinolone-FQ
Levofloxacin
Moxifloxacin
Betalactum B
Ceftriaoxone Cefotaxime
B Inhibitor BI
Gatifloxacin
Trovafloxacin
Doxycycline
71
Antibiotic
Doxyclycline
Azithromycin
Clarithromycin
Telithromycin
Levofloxacin
Gatifloxacin Moxifloxacin Gemifloxacin Amoxyclav Ceftriaxone
72
Ertapenum
74
75
76
Duration of Therapy
Minimum of 5 days Afebrile for at least 48 to 72 h No > 1 CAP-associated sign of clinical instability Longer duration of therapy If initial therapy was not active against the identified pathogen or complicated by extra pulmonary infection
78
Survival (%)
79
FQ + AZ B 3G + AZ
81
If overall clinical picture is otherwise favorable, hemodynamically stable; can switch to oral therapy while still febrile.
83
84
CAP Complications
Hypotension and septic shock
NOSOCOMIAL PNEUMONIA
87
88
Nosocomial Pneumonia
Epidemiology Common hospital-acquired infection Occurs at a rate of approximately 5-10 cases per 1000 hospital admissions Incidence increases by 6-20 fold in patients being ventilated mechanically. One study suggested that the risk for developing VAP increases 1% per day Another study suggested, highest risk occur in the first 5 days after intubation 89
Etiology
Early vs. Late VAP1
Early onset= Pneumonia develops within 96 hours (4 days) of patients admission to the ICU or intubation for mechanical ventilation
Late onset= Pneumonia develops after 96 hours (4 days) of patients admission to the ICU or intubation for mechanical ventilation Very early onset= within 48 hours after intubation2
1
CDC.gov. Guidelines for preventing health-care-associated pneumonia, 2003. DR. The microbiology of ventilator-associated pneumonia.
2 Park
90
Nosocomial pneumonia
91
50
P<.001
P = .504
* *
40 30 20
*
10
0
*Upper 95% confidence interval
None
Early Onset
Late Onset
Nosocomial Pneumonia
92
Nosocomial Pneumonia
Hence, the importance of focusing on:
Accurate diagnosis
Appropriate treatment Preventive measures
93
Nosocomial Pneumonia
Pathogenesis
Risk factors
Etiologic agents Differential diagnosis Treatment Prevention
94
Nosocomial Pneumonia
Pathogenesis
Pathogenesis
Microaspiration may occur in up to 45% of healthy volunteers during sleep
Oropharynx of hospitalized patients is colonized with GNR in 35-75% of patients depending on the severity and type of underlying illness
Multiple factors are associated with higher risk of colonization with pathogenic bacteria and higher risk of aspiration Invasion of the lower respiratory tract by:
Oropharyngeal colonization
Scannapieco et al showed a transition in the colonization of dental plaques in patients in the ICU Control=25 subjects presenting to preventive dentistry clinic Study group=34 noncardiac patients admitted to medical ICU at VA hospital (sampled within 12 hours of admission and every third day)
Scannapieco et al. Colonization of dental plaque by respiratory pathogens in medical intensive care patients
97
Colonization of oropharynx
Medical ICU (N=34) Dentistry Clinic (N=25)
Species
Plaque
Mucosa
Plaque
Mucosa
S. aureus P. aeruginosa
2 8
5 7
0 0
1 0
K. pneumoniae
S. marcescens E. aerogenes E. cloacae E. asburiae P. mirabilis E. coli C. diversus A. calcoaceticus Pasteurella spp. Total
2
3 0 1 0 1 0 1 0 0 18
5
4 0 1 0 0 1 1 1 0 24
0
0 0 0 0 0 0 0 0 1 1
0
0 1 0 1 0 0 0 0 0 3
Scannapieco et al. Colonization of dental plaque by respiratory pathogens 98 in medical intensive care patients
GI colonization
Increased gastric pH leads to bacterial overgrowth
99
Safdar et al. The pathogenesis of ventilator-associated pneumonia: its relevance to developing effective strategies for prevention
100
Nosocomial Pneumonia
Risk Factors
Acinetobacter species
102
Nosocomial Pneumonia
Risk Factors
Host Factors
Extremes of age, severe acute or chronic illnesses, immunosupression, coma, alcoholism, malnutrition, COPD, DM
Factors that enhance colonization of the oropharynx and stomach by pathogenic microorganisms
admission to an ICU, administration of antibiotics, chronic lung disease, endotracheal intubation, etc.
103
Nosocomial Pneumonia
Risk Factors
Conditions favoring aspiration or reflux
Supine position, depressed consciousness, endotracheal intubation, insertion of nasogastric tube
Mechanical ventilation
Impaired mucociliary function, injury of mucosa favoring bacterial binding, pooling of secretions in the subglottic area, potential exposure to contaminated respiratory equipment and contact with contaminated or colonized hands of HCWs
104
4.High frequency of antibiotic resistance in the community or in the specific hospital unit
5.Presence of risk factors for HCAP including: hospitalization for two days or more in the preceding 90 days; residence in an extended care facility; home infusion therapy; chronic dialysis; home wound care; and a family member with an MDR pathogen 105 6.Immunosuppressive disease and/or therapy
Nosocomial Pneumonia
Etiologic Agents
S.aureus
Enterobacteriaceae P.aeruginosa
Acinetobacter sp.
Polymicrobial Anaerobic bacteria
Legionella sp.
Aspergillus sp. Viral
107
40
Early-onset NP Late-onset NP
PA = P aeruginosa OSSA = Oxacillin-sensitive S aureus ORSA = Oxacillin-resistant S aureus ES = Enterobacter species SM = S marcescens
35 30 25
P = .043
P = .408
20 15 10 5 0 PA OSSA ORSA ES SM
P = .985
P = .144
Nosocomial Pneumonia
Diagnosis
Not necessarily easy to accurately diagnose HAP
Radiographic
new or progressive infiltrates on CXR,
Laboratorial
leukocytosis or leukopenia
Microbiologic
Suggestive gram stain and positive cultures of sputum, tracheal aspirate, BAL, bronchial brushing, pleural fluid or blood
109
Quantitative cultures
Nosocomial pneumonia
Bronchoscopically Directed Techniques for diagnosis of VAP and Quantitative cultures
Bronchoscopy with BAL/bronchial brushings (10,000 to 100,000 CFU/ml and less than 1% of squamous cells) Protected specimen brush method (>10 CFU/ml) Protected BAL with a balloon tipped catheter (>5% of neutrophils or macrophages with intracellular organisms on a Wright-Giemsa stain)
110
Nosocomial Pneumonia
Differential diagnosis
ARDS
Pulmonary edema Pulmonary embolism
Atelectasis
Alveolar hemorrhage Lung contusion
111
Nosocomial Pneumonia
Duration of antimicrobial treatment
Optimal duration of treatment has not been established
112
113
8days 15 days
Mortality
Recur Infec
114
Nosocomial Pneumonia
Preventive Measures
Incentive spirometry
Promote early ambulation Avoid CNS depressants
115
Nosocomial Pneumonia
Preventive Measures
Avoid prolonged nasal intubation
Suction secretions Semi-recumbent position( 30-45head elevation)
Do not change ventilator circuits routinely more often than every 48 hours
Drain and discard tubing condensate Use sterile water for respiratory humidifying devices Subglottic secretions drainage
116
Nosocomial Pneumonia
Preventive Measures
Remove NGT when no longer needed
Avoid gastric overdistention Stress ulcer prophylaxis:
sulcrafate; antacids; H2 receptor antagonists
118
Role of gastric pH
gastric pH by H-2 blockers or antacids HAP Sucralfate >ranitidine>antacid = 10% > 6% > 4%
84% late-onset GNB pneumonia have gastric colonization with the same bacteria before pneumonia developed CONCLUSION: Stress ulcer prophylaxis with sucralfate reduces the risk for late-onset pneumonia in ventilated patients compared with antacid or ranitidine
120
121
The preventative effects of SDD for HAP have been considerably lower in ICUs with high rates of endemic MDR pathogens
122
Patient positioning
Several studies supine position vs semirecumbent predisposed to microaspiration of gastric contents lower incidence of both clinically suspected and microbiologically confirmed HAP in semirecumbent versus supine patients No difference in mortality Suggest : place intubated patients in the semirecumbent position unless contraindicated. 123
Patient positioning
Lateral slight-Trendelenburg position achieved with the bed tilted few degrees below horizontal
Current Opinion in Critical Care 2011, 17:5763 Ventilator-associated pneumonia: role of 124 positioning
Subglottic drainage
(CASS)
125
126
Kollef et al. A randomized clinical trial of continuous aspiration of Subglottic secretions in cardiac surgery patients
127
2) Condensate
3) Silver-lined ET tubes
128
129
Randomized clinical trial looking at circuit change every 7 days vs. no routine circuit change
Study group incidence=24.5%
130
Condensate management
Heat-moisture exchanger
Theoretical advantage=prevents bacterial colonization of tubing
Studies= Mixed results Disadvantage=increases dead space and resistance to breathing
131
NEBULISERS
Recommendations from theminutes of meeting in GOA 2013 (THE FUTURE OF NEBULISATION). Panel of 28 pulmonologists from all over india.
132
Safety isues of nebulisers in home Safety isues of using nebulisers in in patients and icu Developing guidelines regarding adequate care and proper usage of nebulisers. Change of tubings and masks.
133
Silver-lined ET tube
Broad-spectrum antimicrobial activity in vitro
134
135
1) Baseline
2) When VAP is clinically suspected 3) 3 days later
136
Diagnosis
Imaging
Gram's stain and culture Bronchoscopy
138
- steroids
- presence of Pseudomonas aeruginosa 1 microbiological findings are useful mainly based on two rules: 1. the presence of intracellular bacteria 2. a positive Gram stain (or other direct tests) may be of great help in selecting the initial antibiotic regimen but not in making the diagnosis of pneumonia 2 The diagnostic technique used, bronchoscopic or tracheal aspirate with quantitative cultures, does not influence either the rate of de-escalation or of mortality 3
1. Eur J Microbiol Infect Dis 1994;13:549558 2. Chest 2001;120:95570 3. Crit Care Med 2004;32:218390
140
Bronchoscopy
Protected brush specimen (PBS) Using a threshold of >103 colony forming units (CFU)/mL
sensitivity : 64 to 100 % specificity : 60 to 100 %
At least 4 studies concluded that bronchoscopically directed techniques were not more accurate for diagnosis of VAP than clinical and X-ray criteria, combined with cultures of tracheal aspirate
141
143
144
TABLE 3. INITIAL EMPIRIC ANTIBIOTIC THERAPY FOR HAP OR VAP IN PATIENTS WITH NO KNOWN RISK FACTORS FOR MDR PATHOGENS, EARLY ONSET, AND ANY DISEASE SEVERITY Potential Pathogen
Streptococcus pneumoniae
Recommended Antibiotic*
Ceftriaxone
Haemophilus influenzae
or
Levofloxacin, moxifloxacin, or ciprofloxacin
or
Escherichia coli
Klebsiella pneumoniae Enterobacter species Proteus species
Ampicillin/sulbactam
or Ertapenem
Serratia marcescens
* See Table 5 for proper initial doses of antibiotics. The frequency of penicillin-resistant S. pneumoniae and multidrug-resistant S. pneumoniae is increasing; levofloxacin or moxifloxacin are preferred to ciprofloxacin and the role of other new quinolones, such as gatifloxacin, has not been established.
145
TABLE 4. INITIAL EMPIRIC ANTIBIOTIC THERAPY FOR HAP OR VAP IN PATIENTS WITH LATE-ONSET DISEASE OR RISK FACTORS FOR MDR PATHOGENS, AND ANY DISEASE SEVERITY
Potential Pathogen
Pathogens listed in Table 3 and MDR pathogens Pseudomonas aeruginosa Klebsiella pneumoniae (ESBL) Acinetobacter species
Linezolid or vancomycin
* Initial antibiotic therapy should be adjusted or streamlined on the basis of microbiologic data and clinical response to therapy. If an ESBL strain, such as K. pneumoniae, or an Acinetobacter species is suspected, a carbepenem is a reliable choice. If L. pneumophila is suspected, the combination antibiotic regimen should include a macolide (e.g., azithromycin) or a fluoroquinolone (e.g., ciprofloxacin or levofloxacin) should be used rather than an aminoglycoside. If MRSA risk factors are present or there is a high incidence locally.
146
Aerosolized antibiotics have not been proven to have value in the therapy of VAP.
147
148
- structural pulmonary disease - 1 week of prior hospitalization - prolonged periods of intubation (>5 days) - prior exposure to antibiotics A. Baumannii VAP: - neurosurgery - ARDS - head trauma - large-volume pulmonary aspiration.
149
150
Prospective, randomized, double blind clinical trial 51 French ICUs 401 patients with VAP (quantitative culture results) Clinical effectiveness comparable, with the possible exception of VAP caused by non fermenting GNR
151
152
153
154
155
156
157
158
Lobar Pneumonia
159
160
161
162
163
Complications of Pneumonia
164
Empyema
165
Mycoplasma Pneumonia
166
Mycoplasma Pneumonia
167
Chlamydia Trachomatis
168
169