infezioni polmonari: gestione diversa per hap & vap · – ppi ? – diuretics ? 3 sorelle ???...

Infezioni polmonari: gestione diversa per HAP & VAP ?

Massimo Girardis

Gruppo di studio SIAARTI

Infezioni e Sepsi in Terapia Intensiva

The panel unanimously decided that HCAP should not be included in the HAP/VAP guidelines.

It was thought that this could be included in the upcoming CAP guidelines because patients with HCAP frequently present from the community and are initially cared for in emergency departments.

There is increasing evidence that many patients defined as having HCAP are not at high risk for MDR pathogens

Recommendations regarding coverage for MDR pathogens among HCAP who develop pneumonia would likely be based on validated risk factors

EARLY

LATE

INFECTIONS & AMS is an issue in ICU ?

Epidemiology - Difficult Infections

Data from infection section - adult population

YEAR 2013 - 162 ICUs- N = 53776

O Patients infected at admission: 19,0%

O Pneumonia 38% (HAP 40 %) O MDR Gram Pos 13 %, Gram Neg 26 %, Res Carba 15%

O Shock 25%, Sepsi grave 37%, Batteriemica 12%

O Mortalità TI 28%, H 38%

O Patients infected during stay: 8,1%

O Pneumonia 39% (VAP 85%) O MDR Gram Pos 13 % MDR Gram Neg 30 % Res Carba 19%

O Batteriemica 21 %

O Mortalità TI 27%, H 32%

Study/Dbase: HELICS (study BURDEN) Population: 119699 ICU patients (> 2 days), 2005-2008, 537 ICUs (Spain France, Austria, Other Europe Results: • Incidence: HAP 8525 (7%), VAP 7675 (90% of HAP) • Microorganisms Ps. Aeur. 20,2% (I/R 22%); Staph Aur. 18, 2% (MRSA 34%) E.coli 7,8% (I/R 11%) A. Baum. 5,9% (I/R 75%)

• HAP/VAP x 2 risk of ICU mortality • MDR low effect on ICU mortality

1. Individual patient data for 6284 patients from 24 trials.

2. Attributable mortality was close to zero in trauma, medical patients, and patients with low or high severity of illness scores.

3. The overall attributable mortality was 13%, with higher mortality rates in surgical patients and patients with mid-range severity scores at admission

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

In Patients With Suspected HAP/VAP, to Decide Whether or Not to Initiate

Antibiotic Therapy:

- PCT Plus Clinical Criteria

- CRP Plus Clinical Criteria

- sTREM-1 Plus Clinical Criteria

- CPIS Plus Clinical Criteria

- Clinical Criteria Alone

For patients with suspected HAP/VAP, we recommend using clinical criteria alone rather than Biomarkers or Scores

Should Patients With Suspected VAP Be Treated Based on the Results a)Invasive Sampling (ie, Bronchoscopy, Blind Bronchial Sampling) With Quantitative

Culture Results, b)Noninvasive Sampling (ie, Endotracheal Aspiration) With Quantitative Culture

Results, c) Noninvasive Sampling With Semiquantitative Culture Results

Should Patients With Suspected HAP Be Treated Based on the Results of Microbiologic Studies Performed on Respiratory Samples, or Should Treatment Be Empiric?

We suggest noninvasive sampling with semiquantitative cultures to diagnose VAP, rather than invasive sampling with quantitative cultures and rather than noninvasive sampling with quantitative cultures (weak recommendation, low-quality evidence).

We suggest that patients with suspected HAP (non-VAP) be treated according to the results of microbiologic studies performed on respiratory samples obtained noninvasively (spontaneous expectoration, sputum induction, nasotracheal suctioning) (weak recommendation, very low-quality evidence).

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

In patients with suspected VAP, we recommend including coverage for S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli in all empiric regimens (strong recommendation, low-quality evidence).

When MRSA a) Risk factor b) units where >10%–20% of S.

aureus isolates are methicillin resistant.

c) patients in units where the prevalence of MRSA is not

When 2 Abx Anti-Pseudo a) Risk factor b) units >10% of gram-negative

isolates are resistant to an agent considered for monotherapy,

c) local antimicrobial susceptibility rates are not available

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

In patients with suspected HAP, we recommend including coverage for S. aureus (strong recommendation, low-quality evidence).

When MRSA a) Risk factor b) units where >10%–20% of S.

aureus isolates are methicillin resistant.

c) patients in units where the prevalence of MRSA is not

For patients with HAP who are being treated empirically, we recommend prescribing antibiotics with activity against P. aeruginosa and other gram-negative bacilli (strong recommendation, very low-quality evidence).

When 2 AntiPseudo a) Risk factor MDR HAP b) High risk Mortality: Shock or

mechanically ventialted

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

INFECTIONS & AMS in ICU

Methods in ICU

O PCT guided prescribing: O Reduces antibiotic usage when used as a de-escalation/stop trigger

without increase of mortality O Does not improve outcomes when used as an escalation trigger alone

Study/Dbase: IMPACT-HAP (US 4 University Hospitals Population: 413 ICU patients with pneumonia pre-after implementation program (2006-2007) 303/413 (73%) at risk for MDR 174/303 (57%) no compliant guidelines

Infezioni polmonari: gestione diversa per HAP & VAP ?

TAKE HOME PICTURE

INFECTIONS & AMS is an issue in ICU ?

Use of Antibiotics

O ICU interventions - TOP 5 (% patients)

1. Antibiotics 75,4% Prophylaxis 49%

Empiric 25%

Targeted 16%

2. MV 72,9%

3. Parenteral nutrition 38,3%

4. Vasoactive drugs 35,9%

5. Enteral nutrition 30,1%

Data from adult population with ICU admission ≥ 24 hours

YEAR 2013 - 178 ICUs- N = 34262

Maybe also :

– Oxygen ?

– Fluids ?

– PPI ?

– Diuretics ?

3 sorelle ???

INFECTIONS & AMS is an issue in ICU ?

Empiric Antibiotic Therapy ? Clinical

Signs Clinical history (Community-Nosocomial)

Source (s) infection

Micro-organisms epidemiology Organ dysfunction (s)

(liver –kidney)

PK/PD

RCT EBM

Manage ICU Abx resistances

INFECTIONS & AMS is an issue in ICU ?

Empiric Antibiotic Therapy and Outcome

i. Time ii. Molecule iii. Dose

INFECTIONS & AMS is an issue in ICU ?

Antibiotic Dose ?

O Prospective, 68 ICUs; β-lactam blood concentration

O 361 patients 69%/31% infection/prophylaxis; 67%/33% bolus /continuous

O High variability

O 50% fT > MIC: • 80% of patients bolus • 93% of continuous

O In the 16% patients without 50% fT > MIC reduced probability of positive outcome (OR 0,68 CI 0,51-0,91)

End-dose interval

INFECTIONS & AMS is an issue in ICU ?

Intensivist: which education in AMS?

O Graduate Program ?

O Residence Program ?

O Post-graduate education (congress, courses) ? O SIAARTI 2014 ~ 5% of lectures, no PG course

O ESICM 2014 ~ 8% of lectures, no PG course

O ISICEM 2015 ~ 10% of lectures (majority sponsored), no PG course

O SMART 2015 ~ 3% of lectures, 1 PG course

INFECTIONS & AMS in ICU

Sepsis Stewardship Programs Mortality = ES 0,66 (0,61-0,72)

INFECTIONS & AMS in ICU

How to face with ?

O Survey 2011, questionnaire, 175 ICUs

INFECTIONS & AMS in ICU

ID in ICU

INFECTIONS & AMS in ICU

ID in ICU

O Medical ICU, 3 months pre-post, 264 patients O Appropriateness of AbTX: 63% -> 88%

O DDD reduction O Overall (- 12%) O Pip/Tazo (-5%) O Vanco & Linezolid (-

5%), O Metro (-91%) O Carba (-41%)

O Reduction of MV days: 10-> 6 days O Reduction of ICU LOS: 11-> 8 days O Reduction of H mortality (no ICU) 37% ->24%

10 DOTI NECESSARIE 1. Deve sapere cosa è un paziente critico 2. Deve sapere quali farmaci sono usati (interazione), volumi di

distribuzione pazienti con shock , come funziona CRRT. 3. Deve fare un pezzo della sua vita clinica con noi (non veni-vidi-

prescriba). Non può essere ogni settimana diverso 4. Deve rispondere al telefono sempre quando vede il numero della ICU

(è urgente) 5. Deve condividere le scelte etiche, i successi e gli insuccessi (anche con

i parenti) 6. Deve essere coinvolto-responsabile nella gestione del budget 7. Deve sapere usare leadership ma anche fellowship 8. Deve provvedere e seguire protocolli uguali per le condzioni

‘standard’ per non creare s.me del druido (e della pozione magica) 9. Deve tenere la contabilità delle infezioni e delle resistenze. 10. Deve portare le brioche calde al giro del mattino (meglio alla

marmellata di albicocca)

INFECTIONS & AMS in ICU ID in ICU ?

INFECTIONS & AMS in ICU

ID in ICU ?

TAKE HOME PICTURE

INFECTIONS & AMS is an issue in ICU ?

How to face with ?

O Survey 2011, 175 ICUs questionnaire

OBIETTIVO: Rispondere a 3 domande:

COSA (definzioni ed indicatori) ENTITA’ (quanto e qualità) EFFETTO – CLINICA (outcome, gestione clinica)

PROBLEMI Gran parte studi sono volontari senza QUALY-control

Popolazione e definizioni eterogenee (specialmente per HCAP)

Pochi studi interventistici….

Studi interventistici (Ab Terapia) sono osservazionali, retrospettivi e pre/post (livello II-III)

3147 patients (>24 H), 198 EU ICUs

1-15 May 2002

No Sepsis 1970 (60%), H mort 17%

Sepsis 1177 (40%), H mort 36%

25%

Microbiology: - Enterboacteriaceae (E.coli, Kleb, Proteus, Serratia) most common, then Staph Aur , Ps Ae - High incidence of A. baumannii. - No differences between HAP and VAP

*

*

Microbiology EARLY vs LATE VAP:

- MORE MSSA, H. Influ, Strep Pn

- LESS Ps Aeur, A. Baumannii

- LESS High risk organism

* *

Microbiology Country Staph Aur e Ps. Aeur more frequent 1° 2° High incidence A.Baum in Greece and Turkey E.coli frequent Germany and Belgium

Study/Dbase: EU-VAP/CAP

Population: 2436 ICU patients (> 2 days and

ventilated), 27 ICUs from 9 EU countries

Results:

• VAP:

•Trauma 128/354, 36%

•No trauma 337/2082, 16%,

• ICU Mortality:

•Trauma 22/128, 17%

•No Trauma 142/337, 43%

• Micro-organism:

• Trauma early (67): 74% No resistant bacteria

• Trauma late (64): 37% No resistant bacteria

Collaborative Italian Group

for Intensive Care Unit Vigilance

GiVITI 2009

Project “Margherita”

Collaborative Italian Group for Intensive Care Unit Vigilance

GiVITI 2009

Collaborative Italian Group for Intensive Care Unit Vigilance

GiVITI 2009

> 4 gg

Polmonite associata a ventilazione meccanica invasiva, da + 2 gg inizio a + 2 gg dopo

Collaborative Italian Group for Intensive Care Unit Vigilance

GiVITI 2009

38

44

70

23 50

41 46

Definizione Originale

+

CAP H-CAP HAP VAP

Kollef 2005 59 US Hospitals 4543 patients with culture positive pneumonia in H in the first 5 days (2002-2003)

49% 22% 18% 11%

Carratalà 2007

1 Spanish Hospital 727 patients with pneumonia in ED (2001-2004)

83% 17%

Micek 2007

1 US Hospital 639 patients with culture positive in ED (2003-2005) (HCAP ATS criteria + 12 months hospitalization+ immunsup.)

33% 67%

Venditti 2009

55 Italian Hospitals 59 Medical divisions 362 patients with pneumonia (1 week January + 1 week July 2007)

61% 25% 24%

• Più anziani vs CAP • Più co-morbidità vs CAP • Più Score gravità polmonite vs CAP • Più ricoveri ICU vs CAP • Più mortalità vs CAP

Differenze tra studi determinate da differenze popolazione e disegno

3 sorelle ???

Collaborative Italian Group

for Intensive Care Unit Vigilance

GiVITI 2009

Project “Margherita”

Collaborative Italian Group for Intensive Care Unit Vigilance

GiVITI 2009

Collaborative Italian Group for Intensive Care Unit Vigilance

GiVITI 2009

0,45 0,66

0,56 0,29 0,57

0,57

3147 patients (>24 H), 198 EU ICUs 1-15 May 2002 No Sepsis 1970 (60%), H mort 17% Sepsis 1177 (40%), H mort 36%

25%

Collaborative Italian Group

for Intensive Care Unit Vigilance

GiVITI

Project “Margherita”