Ventilator-acquired pneumonia

For example. Memorial Hermann used nine measures developed by the Institute for Healthcare Improvement as a starting point for reducing ventilator-acquired pneumonias (VAPs) and increasing safety and quality of care for ventilated patients. Individuals traveled to an IHI collaborative meeting and then returned to Memorial Hermann and passed on what they had learned to multidisciplinary teams from each of the hospital system s ICUs. 

Prevention of Hospital-Acquired and Ventilator-Associated Pneumonia... 

List the common pathogens that cause community-acquired pneumonia, aspiration pneumonia, ventilator-associated pneumonia (early versus late onset), and health care-associated pneumonia. 

Recognize the signs and symptoms associated with community-acquired pneumonia and ventilator-associated pneumonia. 

Design an appropriate empirical antimicrobial regimen based on patient-specific data for an individual with community-acquired pneumonia, aspiration pneumonia, and ventilator-... 

Pneumonia is inflammation of the lung with consolidation. The cause of the inflammation is infection, which can result from a wide range of organisms. There are five classifications of pneumonia community-acquired, aspiration, hospital-acquired, ventilator-associated, and health care-associated. Patients who develop pneumonia in the outpatient setting and have not been in any health care facilities, which include wound care and hemodialysis clinics, have community-acquired pneumonia (CAP). Aspiration is of either oropharyngeal or gastrointestinal contents. Hospital-acquired pneumonia (HAP) is defined as pneumonia that occurs 48 hours or more after admission.1,2 Ventilator-associated pneumonia (VAP) requires endotracheal intubation for at least 48 to 72 hours before the onset of... 

In approximately 10% of patients, community-acquired pneumonia will be severe enough to require intensive care or mechanical ventilation. 

Community-acquired pneumonia Health care-associated, ventilator-asociated, or nosocomial pneumonia (Early onset no risk factors for MDR pathogens) Third-generation cephalosporin plus a macrolide or doxycycline Third-generation cephalosporin OR Fluoroquinolone OR Ampicillin-sulbactam OR Ertapenem... 

Treatment for septic patients with hospital-acquired, ventilator-acquired, and health care-associated pneumonia is dependent on risk factors for multi-drug resistant (MDR) organisms (Fig. 79-2). Recommended treatment for patients with no MDR risk factors are third-generation cephalosporins, fluoroquinolones, ampicillin-sulbactam, or ertapenem (see Table 79-3).35 Recommended treatment for patients with MDR risk factors are P-lactam/p-lactamase inhibitors (piperacillin-tazobactam), antipseudomonal cephalosporin, or carbapenem, plus an aminoglycoside, plus vancomycin or linezolid (see Table 79-3).35 If an aminoglycoside is undesirable, a antipseudomonal fluoroquinolone may be utilized with a P-lactam/p-lactamase inhibitor. 

The spectrum of respiratory tract infections (RTI) can vary from the common cold to acute or chronic bronchitis to community-acquired pneumonia to nosocomial pneumonia and aspiration pneumonia to ventilator-associated pneumonia to chronic pneumonia (in cystic fibrosis, histoplasmosis, tuberculosis, etc.). Important complications are lung abscess and pleural empyema that will often need drainage and prolonged antimicrobial treatment (>6 weeks). 

A later prospective study of 490 patients with COPD who were admitted to hospital with radiologically confirmed community-acquired pneumonia, and of whom 77% were using inhaled glucocorticoids, has provided contradictory evidence [4 ]. There were no differences in any of the pneumonia severity markers between users of inhaled glucocorticoid and non-users. Multivariate analysis, after adjustment for COPD severity and pneumonia severity, showed that inhaled use of glucocorticoids was not independently associated with 30-day mortality (OR=1.7 95% CI=0.75, 3.9), 6-month mortality (OR = 1.6 95% Cl=0.82, 3.2), requirement for mechanical ventilation and/ or inotropic support (OR = 0.73 95%... 

Observational studies Stress ulcer prophylaxis with ranitidine has been associated with an increased risk of ventilator-associated pneumonia. The use of proton pump inhibitors has also been linked to an increased risk of community-acquired pneumonia, and pantoprazole is commonly used in stress ulcer prophylaxis. In a retrospective observational study the database of a cardiothoracic surgery unit was used to identify all patients who had received stress ulcer prophylaxis with pantoprazole or ranitidine 887 patients met the inclusion criteria [66% Nosocomial pneumonia was... 

A 60-year-old male with known cerebral palsy and epilepsy on phenytoin and clobazam, presented to emergency department with a community-acquired pneumonia which was treated with levofloxacin. Phenytoin levels on admission were high and therefore phenytoin was omitted until levels were in the therapeutic range. Ten days into admission, he developed status epilepticus that necessitated intubation and ventilation for airway protection. Continuous EEC monitoring showed nonconvulsive status epilepticus. 

According to the CDC, almost 1.7 million hospital-acquired infections (HAIs) occur yearly, contributing to approximately 99,000 deaths. Such infections were long accepted by clinicians as an inevitable hazard. Recent efforts demonstrate that simple measures can prevent the majority of common infections. Hospitals and providers must work to reduce the burden of these infections. Four specific infections account for more than 80 percent of all hospital-related infections. They are surgical site infections, catheter-associated urinary tract infections, central venous catheter-related bloodstream infections, and ventilator-associated pneumonia. Preventing the transmission of antibiotic-resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) remains an important infection control priority. Effective measures exist to prevent the most common healthcare-related infections. 

Torres A, Aznar R, Gatell JM, et al. Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients. Am Rev Respir Dis 1990 142 523-528. Sopena N, Sabria M, and the Neumos Study Group. Multicenter study of hospital-acquired pneumonia in non-lCU patients. Chest 2005 127 213-219. 

Torres A, Ewig S. Diagnosing ventilator-associated pneumonia. N Engl J Med 2004 350 433 35. loanas M, Cavalcanti M, Eerrer M, et al. Hospital-acquired pneumonia coverage and treatment adequacy of current guidelines. Eur Respir J 2003 22 876-882. 

Niederman M, Craven D. Guidelines for the management of adults with hospital-acquired pneumonia, ventilator-associated pneumonia, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005 171 388 16. 

Epidemiological studies evaluating adverse effects of nosocomial infections indicate that pneumonia is the leading cause of death from infections acquired during the hospital stay. Table 3 summarizes six studies that have reported crude mortality rates of ventilator-associated pneumonia ranging from 33% to 71% (20). 

Kirton OC, DeHaven B, Morgan J, Morejon O, Civetta J. A prospective, randomized comparison of an in-line heat moisture exchange filter and heated wire humidifiers Rates of ventilator associated early-onset (community-acquired) or late-onset (hospital-acquired) pneumonia and incidence of endotracheal tube occlusion. Chest. In Press. 

There are five classifications of pneumonia community-acquired, aspiration, hospital-acquired, ventilator-associated, and health care-associated. 

Incidence density is the instantaneous rate at which disease is occurring, relative to the size of the disease-free population. Incidence density is measured in units of the number of cases of disease per person per unit of time. An example of an incidence density that is commonly used in hospitals is the number of nosocomial pneumonias per 1000 ventilator-days. Incidence density is useful when the infection rate varies in a linear fashion to the length of time a patient is exposed to a risk factor (i.e., the longer the patient is exposed, the greater the chance of acquiring infection). For example ... 

Torres A, El-ebiary M, Gonzalez J, Eerrer M, Puig de la Bellacasa J, Gene A, et al. Gastric and pharyngeal flora in nosocomial pneumonia acquired during mechanical ventilation. Am Rev Respir Dis 1993 148 352-357. 

According to the time of diagnosis, VAP can be subdivided into early-onset (diagnosed within the first 4 days of ventilation) and late-onset disease (diagnosed after more than 4 days of ventilation) (11). Early-onset VAP is usually caused by community-acquired bacteria colonizing the upper respiratory tract before hospital admission (e.g.. Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus), these are presumably aspirated... 

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