ICUNosocomialPneumonia.pptVIP

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 ? 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 mortal