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Nosocomial and Aspiration Pneumonia

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Hospital Acquired Pneumonia (HAP)
-Pneumonia that occurs >/= 48 hours after hospital admission
-Not incubating at time of admission
Ventilator-Associated Pneumonia (VAP)
-Pneumonia that occurs >/= 48 hours after endotracheal (ET) intubation/mechanical ventilation
How to manage patients that require ET intubation after developing severe HAP?
Manage similar to VAP
Healthcare Associated Pneumonia (HCAP) Risk Factors
1) Patients have >/= 2 risk factors for MDR pathogen

2) Hospitalization in an acute care hospital for >/= 2 days within 90 days of current infection

3) Nursing home or long-term care facility resident

4) Within 30 days of current infection received
-Home infusion/IV antibiotic therapy
-Home wound care therapy
-Chemotherapy
-Hemodialysis (HD) at a hospital/clinic
Early onset of pneumonia
-Occurs within the first 4 days of hospitalization

-More likely antibiotic sensitive pathogens

-Carries a better prognosis
Late onset of pneumonia
-Occurs on day 5 or later of hospitalization

-More likely MDR pathogens

-Associated with increase patient morbidity/mortality
Aerobic GNR pathogens
1) Pseudomonas aeruginosa
2) Acinetobacter sp
3) Stenotrophomnas maltophilia
4) Burkholderia cepacia
5) Klebsiella pneumoniae
6) Escherichia coli

7) Citrobacter sp
8) Enterobacter sp (eg. cloacae)
9) Proteus sp (eg. mirabilis)
10) Serratia marcescens
Aerobic GPC pathogens
1) MRSA

2) Staphylococcus aureus
3) Streptococcus viridans
4) Staphylococcus epididemus
5) Neisseria sp
6) Corynebacterium sp (GPR)
Anaerobic GNR Pathogen
RARE in VAP
Multi-Drug resistance pathogens/ ESBL
1) Klebsiella pneumoniae
2) Escherichia coli
Risk factors for MDR pathogens
1) Antimicrobial therapy within past 90 days
2) Current hospitalization for >5days
3) High frequency of antibiotic resistane in community or in specific hospital unit
4) Presence of risk factors for HCAP
5) Family member with MDR pathogen
6) Immunosuppressive disease and/or therapy
7) Healthcare worker
Uncommon pathogen
1) anaerobes (aspiration)
2) Legionella pneumophila
3) Virus (primary viral infection) to secondary bacterial infection
4) Fungus
Where is legionella pneumophila transmitted?
1) Construction areas/excavation sites
2) inhalation of aerosols or microaspiration of contaminated water (air conditioners and showers)
Sources of microorganisms access to lower respiratory tract (LRT)
1) inhalation of aerosolized particles
2) Hematogenous spread from extrapulmonary sites of infection (rare)
3) Aspiration of oropharyngeal contents
4) Leakage of bacteria around endotracheal (ET) tube cuff
5) Healthcare devices or environment
6) transfer between staff and patients (Hand Hygiene)
What is the primary etiology of microorganism access to lower respiratory tract?
Aspiration of oropharyngeal contents
Patient related Risk factors
1) Gender (M>F)
2) Pre-existing pulmonary disease (asthma/COPD)
3) Multiple organ system failure
Treatment related risk factors
1) intubation
2) Enteral feeding
Modifiable risk factors
1) intubation and mechanical ventilation

2) ET tubes

3) Ventilation circuit

4) Supine vs. semi-recumbent positioning

5) Enteral nutrition

6) Modulation of oral colonization

7) Stress ulcer prophylaxis (SUP)

8) Blood transfusions

9) Tight glucose control: 80-110 mg/dL

10) strict infection control
Modifiable Risk Factors: intubation and mechanical ventilation
-noninvasive ventilation to avoid re-intubation
-Sedation/daily wake-up trials to facilitate weaning
Modifiable risk factors: ET tubes
-Oral ET & orogastric vs nasotracheal & NG tubes
-Aspiration of subglottic secretions may decrease HAP risk
-Limit sedatives & paralytic agents
-Maintain ET cuff pressure at >20 cm water
Modifiable risk factors: Ventilator circuit
-frequent changing- no affect on incidence of HAP
-Remove contaminated condensate from circuit
Modifiable risk factors: Supine vs. Semi-recumbent positioning
Semi-recumbent positioning (30-45 degree)
Modifiable risk factors:Enteral Nutrition
-Other risk with total parenteral nutrition (TPN)
-Post-pyloric feeding (decrease risk of aspiration)
Modifiable risk factors: Modulation of oral colonization
-Oral antiseptics: chlorhexidine
-Oral antiseptics: +/- systemic antibiotics
-Selective decontamination of digestive tract (SDD)
Modifiable risk factors: Stress ulcer prophylaxis (SUP)
Use H2RA or PPI instead of sucralfate because sucralfate doesn't affect pH but it increase the risk of bleeding
Modifiable risk factors: Tight glucose control
80-110 mg/dL

NICE-SUGAR: goal <180 mg/dL
Modifiable risk factors: Infection control
-Hand hygiene: soap and water, alcohol based hand disinfection
-contact precautions: gown, gloves
Key diagnosis points
1) Chest X-ray
2) LRT cultures
Suspicion of HAP: Want at least 2 of the finding
1) Radiologic infiltrate that is new or progressive
2) clinical findings suggestive of infection
-New onset of fever
-Purulent sputum
-Leukocytosis or leukopenia
-Decreased oxygenation
Clinical conditions leading to increased suspicion of PNA/warranting further diagnostic testing
-ARDS (acute respiratory distress syndrome)
-Pt w/ unexplained hemodynamic instability or deterioration of blood gases during mechanical ventilation
LRT culture from
1) Endotracheal (ET) aspirates
2) Protected specimen brush (PSB)
3) Bronchoalveolar lavage (BAL)
Consider nosocomial tracheobronchitis
When the following are present:
-Fever
-Purulent sputum
-Leukocytosis
-Sputum or tracheal aspirate culture (+)

But a new lung infiltrate is absent
Presence of pneumonia defined as:
New lung infiltrate
PLUS
2 or 3 clinical features
-Fever
-Leukocytosis or leukopenia
-purulent sputum
Management: clinical strategy
Emphasizes prompt empiric therapy for all patients suspected of having HAP
Management: Bacteriologic Strategy
Uses quantitative LRT cultures to define presence of pneumonia and etiologic pathogen

Don't start ABX till know what pathogen it is
Inappropriate empiric antimicrobial treatment (IEAT)
-use of ABX w/ poor or no in vitro activity against the identified infecting microorganism

-increasing antimicrobial resistance increases probability of IEAT
Empiric ABX therapy for HAP withOUT late onset or risk factor for MDR pathogens
Limited spectrum ABX therapy
Empiric ABX therapy for HAP WITH late onset or risk factor for MDR pathogens
Broad spectrum ABX therapy for MDR Pathogens
Initial empiric antibiotic therapy for HAP/VAP/HCAP with NO risk of MDR pathogen and it is Early onset of pneumonia
1) Ceftriaxone
2) FQ: LVQ, Moxi, Cipro
3) Ampicillin/Sulbactam
4) Ertapenem

Chose ONE
Initial empiric antibiotic therapy for HAP/VAP/HCAP with risk of MDR pathogen and it is LATE onset of pneumonia
One of these
1) Antipseudomonal Cephalosporin (Cefepime or Ceftazidime)
2) Antipseudomonal carbepenem (Imipenem or Meropenem)
3) Beta lactam/beta lactamase inhibitor (Piperacillin/tazobactam)

PLUS ONE of these:
1) Antipseudomonal FQ: (LVQ or Cipro)
2) AMG ( Amikacin or Gentamycin or Tobramycin)

PLUS ONE of these:
1) MRSA coverage: VAncomycin or Linezolid

IF suspect legionella pneumophila:
-substitute AMG for Macrolide (Zithromax)
DOC for Pseudomonas aeruginosa
1) Beta lactam + AMG
2) Beta lactam + FQ
3) Adjunctive inhaled ABX
DOC for Acinetobacter sp
1) Carbapenems (DOC) except ertapenem
2) ampicillin/sulbactam
3) Polymyxin
DOC for ESBLs
1) Carbapenem (DOC)
2) Caution/optimal doses
-4th generation cephalosporin
-AMGs
-FQ
-Piperacillin/tazobactam
DOC for MRSA
1) Vancomycin
2) Linezolid
Patient as risk for HCAP should be treated for potentially _______ organism.
MDR

Regardless of which hospital admission day pneumonia begins
What is most commonly associated with MDR organisms
Inappropriate empiric antibiotic treatment
Optimizing empiric ABX therapy: Key points
-Optimal doses of ABX should be used
-Route of administration: IV first, then PO
-Monotherapy w/ selected agents for severe HAP and VAP may be used in the absence of resistant pathogens
-MDR pathogens suspected : use combo therapy
-AMG included in empiric combo therapy: may d/c after 5-7 days in responding patietnts
-Duration of theapy may be shortened to 7 days if pt started on appropriate therapy and show clinical response and not pseudomonas aeruginosa.
-Aerosolized ABX: adjunctive therapy for GNRs, no proven valvue as mono therapy
Inclusion criteria for adjunctive aerosolized ABX therapy in VAP
1) Mechanical ventilation for >/= 48 hrs
2) VAP diagnosis q/ documented psudomonas aeruginosa, Acinetobacter baumanii, or both , which required aerosolized ABX
Exclusion criteria for adjunctive aerosolized ABX therapy in VAP
1) incomplete medical record
2) Pregnancy
3) Active malignancy or immmunosuppression
4) Received aerosolized ABX for </= 3 days
Advantages of adjunctive aerosolized ABX therapy in VAP
1) Achieve high concentrations of med at site of infection
2) typically have minimal systemic absorption
Adjunctive inhaled ABX administered
1) Tobramycin 300 mg inh q12hrs
2) Amikacin 1000 mg inh q 12 hrs
3) Colistimethate sodium: 150 mg inh q12 hours
Assessing response to therapy
1) Serial assessment of clinical response
-Repeat: CXR, Cultures, Tmax, WBC
-Adjust empiric therapy based on results and micro data

2) Clinical improvement usually takes 48-72 hrs

3) De-escalate ABX therapy in responding patients when allowed per culture data

4) non-responding patients require further evaluation and testing
Assessment of NOnresponders
1) Wrong organism
2) Wrong diagnosis
3) Complication
Assessment of Non-responders: Wrong organism
-Drug resistant pathogen baceria, mycobacteria, virus, fungus, inadequate antimicrobial therapy
Assessment of non-responders: Wrong diagnosis
Atelectasis, PE, ARDs, Pulmonary hemorrhage, underlying disease Neoplasm
Assessment of Non-responders: Complication
- Empyema or lung abscess
- C. difficille colitits
- occult infection
- drug fever
Aspiration
inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract (LRT)
Aspiration pneumonitis
-Acute chemical lung injury
-Caused by inhalation of sterile gastric contents
Aspiration pneumonia
-Infectious process
-caused by inhalation of oropharyngeal secretions colonized by pathogenic bacteria
-development of a radiographically evident infiltrate
What is the #1 cause of death in patients with dysphagia due to neurologic disorder?
Aspiration pneumonia
Risk factors for aspiration pneumonia
1) occurs w/ decreased level of consciousness
-Drug overdose
-Alcohol consumption
-Use of anesthesia/sedative
-Massive CVA
-Coma
-Seizures

2) Elderly patients w/ increased of neurologic disease/dysphagia, poor dentition w/ increased colonization/Abnormal lower esophageal sphincter/GERD

3) Critically ill patients
4)Mechanical intubation
Signs/Symptoms of gastric acid aspiration
1) Coughing
2) SOB
3) Wheezing

Others
4) Cyanosis
5) Pulmonary edema
6) ARDS
7) Death
Damage due to aspiration pneumonitis is depends on what?
1) Acidity of refluxate
2) Volume aspirated
3) Particulate matter (eg. food)
Aspiration pneumonitis: Results in inflammatory reaction
Phase 1: Direct caustic effect of low pH/peaks in 1-2 hours

Phase 2: infiltration of neutrophils & inflammatory mediators into the alveoli and lung interstitium
When is empirical antibiotics appropriate in aspiration pneumonitis patients?
-Small bowel obstruction (SBO) or other conditions associated with gastric contents colonization
-Pneumonitis that fails to resolve within 48 hours
What should be consider when broad spectrum antibiotic is initiated?
-Perform BAL or PSB to determine organism
-Adjust antibiotic as appropriate
Corticosteroids is not recommended in ________________
Aspiration pneumonitis
Common organism in community setting
1) Strep. pneumoniae
2) Staph. aureus
3) Haemophilus influenzae
4) Enterobacteriaceae spp
5) Low incidence of anaerobes
Common organism in healthcare facility setting
1) Kleb. pneumo
2) E. coli
3) Serratia marcenscens
4) Ps. aeruginosa
5) Acinetobacter baumanii
6) Low incidence of anaerobes
Anaerobic coverage not required in aspiration pneumonia except in patient with what?
1) severe periodontal disease
2) Putrid sputum
3) Evidence of necrotizing PNA or lung abscess on CXR
Empiric ABX for Aspiration Pneumonia: pt with s/s lasting >48 hours
1) Ceftriaxone
OR
2) Levofloxacin
Empiric ABX for Aspiration Pneumonia: pt with small bowel obstruction or use of antacids, anti-secretory agents
1) Ceftriaxone
2) Piperacillin/tazobactam
3) Levofloxacin
4) Ceftazidime
5) Ciprofloxacin
Empiric ABX for Aspiration Pneumonia NOT in healthcare facility setting
Levofloxacin OR ceftriaxone
Empiric ABX for Aspiration Pneumonia IN healthcare facility
1) Levofloxacin
2) Ceftazidime
3) Piperacillin/tazobactam
Prevention of Aspiration Pneumonia
1) modify: soft diet, reduce bite size
2)Mechanical ventilation, esp. w/ tube feeding
-Head of bed elevation: 30-45 degree
-Stress ulcer prophylaxis (SUP)
-Oral care
-Daily wake up trials/assessment
Prevention of Aspiration Pneumonia: Vaccinaiton
1) Pneumococcal Vaccine
-Pneumococcal polysaccharide (PPSV)
-Pneumococcal conjugate (PCV13)
-Reduce risk of invasive disease by 60-70%
Who should receive PPSV
1) Pt >/= 65 yo
2) pt 19-64 yo who smoke cigarettes, or have asthma
3) Pt 2-64 yo w/ chronic illness/high risk
-Pulmonary disease
-Cardiovascular disease
-Immunosuppression
-metabolic (DM)
-renal dysfunction
-Hemoglobinopathies (sickle cell disease)
Who should re-administration of PPSV vaccine
-not required if pt was >/= 65 yo when receive first dose
-indicated in pt >/=65 yo if has been at least 5 years since initial vaccination dose
-pt 2-64 yo at highest risk of death who received initial dose >/= 5 years ago
Max dose of PPSV
2 dose
Who should receive PCV13
1) infant and children <2 yo
-routine schedule: 2,4,6, and 12-15 months
2) if received full dosing schedule w/ PCV7, should receive 1 dose of PCV13
-children 14-59 months of age w/ underlying medical condition
Prevention of Aspiration Pneumonia: influenza vaccine
-Trivalent inactivated influenza vaccine (TIV)
-Live attenuated influenza vaccine (LAIV)
____________is the most common complication of influenza with ___________ being one of the most frequent etiologic organisms
1) Pneumonia
2) Strep pneumo
What patients who do not hve any contraindication to vaccine should be immunized with the influenza?
All persons >/= 6 months of age