Ventilator Associated Pneumonia

Omolemo Kitchin

Steve Biko Academic Hospital

Conflict of interest

Nothing to Declare

Outline

Case presentation

Diagnosis and diagnostic dilemma

Prevention

Treatment

What about VAT?

Conclusion

1/12 old ex-prem

Bronchiolitis

NPA- RSV

Ventilated for respiratory failure and

apnoea

48hrs after admission

Temperature increased, Wcc increased

Tachypnoea with increase in ventilator

support

Worsening chest radiograph

Blood cultures negative

Ex-tubated and discharged after 17days

(12 in PICU)

Diagnosis/Dilemma

Morrow BM, Argent AC, Jeena PM, Green RJ. SAMJ 2009

Diagnosis/Definitions

Early VAP(1-4days), late VAP(>4days)1

CPIS -no validation in paediatrics(level D)

-Points:0-2

-temperature, Wcc, tracheal aspirates, PF ratio, CXR,

semi quantitative tracheal aspirate culture.

-Score of>6 high probability of VAP

http://cd-c.gov/nhsn.1 Last accessed Jul 2011

Morrow BM, Argent AC, Jeena PM, Green RJ. SAMJ 2009

Chest radiograph-clinical suspicion( level

B)[3500 PICU pts, non-randomised]

Microbiol and clinical-B/C, BAL(level B)

Infection markers-Wcc, neutrophils,

PCT(level D)

Sputum production, WOB, auscultation-

(level D)

Fever-(level D)

Morrow BM, Argent AC, Jeena PM, Green RJ. SAMJ 2009

Diagnostic dilemma of VAP in critically

ill children(systematic review)

Gold Std-direct exam and lung tx culture

Clinical criteria: poor sens and spec vspathology

CPIS vs pathology(sen 72.7% & spec 42-85%)

Radiology: specificity(33-42%)air bronchograms, infiltrates (sens50-78%)

Microbiol: NBAL & autopsy(sen & spec 100%, n=17)

NBAL compares to BBAL

Tracheal Aspirates-low spec

VenkatachalamV, Hendley OJ, Wilson DF. Pediatr Crit Care Med 2011;12:286-96

Prevention

Infection control: hand, environmental

decontamination (level A)

Bundle approach

-Level A

peptic ulcer prophylaxis(not PICU)

Sedation vacation/readiness to extubate

Morrow BM, Argent AC, Jeena PM, Green RJ. SAMJ 2009

Level B

-Head of bed elevation

-In line suctioning(meta analysis)

-Closed system suctioning did not affect the

frequency of VAP or patient outcome1

-Oral hygiene :level B

twice daily electric tooth brushing

+chlorhexadine oral rinse vs just oral rinse:

no reduction in VAP (OR 0.78 CI 0.36-1.68)2

Morrow BM, Argent AC, Jeena PM, Green RJ. SAMJ 2009

Morrow BM, Mowzer R, Pitcher R,Argent AC. Pediatr Crit Care Med 2011, Jan 28[Epub ahead of print]1

Rello J et al. Intensive Care Med 2007;33:1066-702

Level D

-Post Pyloric feeds

-DVT prophylaxis

-Orotracheal vs nasotracheal intubation

Morrow BM, Argent AC, Jeena PM, Green RJ. SAMJ 2009

OTHERS

Ventilator circuit changes

-2 Paeds studies (n=575)

-1 Adult meta analysis(n=19,169)

-7day changes does not increase VAP’

Nurse led VAP surveillance(UK)

-VAP incidence=5.6/1000 ventilator days1

Han J, liuY. Respir Care 2010;55:467-74

Hsieh TC et al. Pediatr Neonatol. 2010;51: 37-43

Samransamruajkit et al. J Crit cAre 2010; 25:56-61

Richardson M, Hines S, Dixon G et al.1J Hosp Infect. 2010;75:220-4

Treatment

Delay in starting assoc with poor

prognosis

Consider resistance pattern of pathogens

in your hospital

Choose wisely, Start early, hit hard with

the correct dose

Deescalate rapidly, stop abruptly.

Early tracheostomy: Adult-equivocal

:No Paediatric studies Paed Crit Care Med 2011;12:286-296

SAMJ2009

What about VAT?

Adult incidence=10%

Paediatrics ?( 1 study =1.8%)

Diagnostic criteria

-Fever, no recognizable cause

-Purulent sputum production

-(+) endotracheal aspirate culture

-no radiological evidence of pneumonia

Nseir S, Ader F, Marquette CH.Curr Opin Infect Dis 2009;22:148-53

Is it a problem in Paediatrics?

If so, will treating it decrease VAP?

Will the bundles work?

Current study in Ohio-factors assoc with

VAT development and reduction of VAT

rates.

Lee AY, Brilli RJ. Pediatr Crit Care Med 2011;12:357-8

Conclusion

Diagnostic methods are inadequate

Clinical criterea is ambiguous

Gold Std not routine in children

CPIS+NBAL+radiology!

Discretional use of antibiotics

Prevention-Bundles

http://gobblegreen.com/blog/wp-content/uploads/2009/07/wash-hands-cartoon1.jpg

Acknowledgements

Prof Robin J Green

Prof Refiloe Masekela

Dr Marian Kwofie-Mensah

Dr Carla Els

Dr Debbie White

Dr Jeane’ Cloete

Dr Salome Abbot

Sr Zulu and PICU staff