nationallatest updates to the canadian vap guidelines - what's new?

LATEST UPDATES TO THE CANADIAN VAP GUIDELINES

Tuesday, September 30 2014 Mardi 30 Septembre 2014

Your Hosts & Presenters Vos hôtes et présentateurs

Bruce Harries, Collaborative Director Denny Laporta, MD, MSc, FRCPC; ICU Collaborative Chair Intensivist, Dept of Adult Critical Care; Jewish General Hospital; Faculty of Medicine, McGill University John Muscedere, MD, FRCPC Associate Professor, Department of Medicine & Critical Care Program, Queen’s University; Research Director, Critical Care Program; Physician, Kingston General Hospital, Faculty Member Canadian ICU Collaborative Leanne Couves, Improvement Advisor

Ardis Eliason, Technical Host

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Dr. John Muscedere

Latest Updates to the Canadian VAP Guidelines

Canadian Clinical Practice Guidelines

for Ventilator Associated

Pneumonia (VAP) Dr. John Muscedere Queen’s University

Learning Objectives

1. To understand the epidemiology of VAP.

2. To review the principles of diagnosis for VAP

3. To review Clinical Practice Guidelines for VAP:

1. Prevention 2. Diagnosis 3. Treatment

Epidemiology of VAP

Hospital-Acquired Pneumonia (HAP): Definitions Hospital Acquired Pneumonia:

Arises 48 hours or more after hospital admission

Is not incubating at the time of admission Ventilator-associated pneumonia (VAP):

Arises 48-72 hours or more after endotracheal intubation (up to 48 -72 hours after endotracheal intubation)

Healthcare-associated pneumonia (HCAP): Arises within 90 days of admission to an

acute care facility or residence in NH/LTCF.

(American Thoracic Society/IDSA. Am J Respir Crit Care Med 2005;171:388-416)

Hospital Location & Relative Frequency of HAP & VAP

HAP

ICU HAP

Non-ICU HAP VAP

Non-ICU HAP ICU HAP VAP ICU HAP

HAP ICU

Why the focus on VAP? Increased Mortality

Depends on population Adequacy and timeliness of antibiotic treatment

Melsen et al, Crit Care Med, 2009

Baekert et al, AJRCCM, 2011

Melsen et al, SR and MA of 52 Obs. studies, 17,000 patients RR 1.27 (1.15,1.39)

Relative: 4- 6% of ICU Mortality Absolute: 1 – 1.5% Mortality

VAP: Impact Increases ICU Stay, Increases duration of

Mechanical Ventilation and Increases duration of Hospital Stay Extra days in the hospital: 4-9 days Average extra days in ICU: 4.3 days

VAP: Canadian Healthcare Costs

1Based on attributable mortality of 5.8% 2Ontario cost cost methodology Muscedere et al, J Crit Care, 2008

Cost per Case $11,450 Burden of Illness per year: Assuming 10.6

cases/1000 Vent days Excess Vent

days 16,000 days

(55 ICU beds) Excess Deaths1 216

Excess Cost2 $46,000,000

Incidence

• Depends on how hard one looks • Surveillance underestimates true

incidence • Reported rates vary:

• USA: NHSN 2-10 Cases/1000 vent days • Ontario: 2.8 Cases/1000 vent days • Multi-center Canadian study: 9 Cases/ 1000

vent days

Pathogenesis of HAP/VAP

Pathogenesis of VAP

Causative Pathogens

Classification of HAP & VAP: Risk Stratification

Time from Hospitalization (days)

Time from Intubation (days)

Early-onset VAP Late-onset VAP

Late-onset HAP Early-onset HAP

0 1 2 3 4 5 6 7

0 1 2 3 4 5 6 7

(American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416)

Pathogens to Consider When Treating HAP/VAP

Early HAP/VAP Late HAP/VAP

Timing Within five days of admission or mechanical ventilation

Five days or more after admission or mechanical ventilation

Bacteriology S. pneumoniae H. influenzae Methicillin-sensitive S. aureus Susceptible gram-negative bacteria

P. aeruginosa Acinetobacter Methicillin-resistant S. aureus Other multi-resistant organisms

Prognosis Less severe, little impact on outcome Mortality minimal

Higher attributable mortality and morbidity

(American Thoracic Society/IDSA. Am J Respir Crit Care Med 2005;171:388-416)

Diagnosis of VAP

• No reference standard for VAP • Clinical features are non-specific and can

be found in many other diseases • CXRay:

– Neither sensitive nor specific – Normal xray can help rule out VAP (? VAT) – No pathognomic features of VAP

Diagnosis of VAP

Clinical + Microbiology

• Purulent secretions • Increasing oxygen requirements

• Core temp > 38.0o C

• WBC <3.5 or > 11.0

+ Chest X-Ray

Pathogenic Bacteria

New or Persistent Infiltrates

Invasive

ETT Aspirate

Obtaining Microbiological Sample for Diagnosis of VAP

Bronchoscopy

Non-Invasive

Quantitative Cultures

Non-Quantitative

Cultures

Mortality of BAL vs ETA

Meta-Analysis of All trials comparing ETA with BAL

Possible pneumonia

Probable pneumonia

VAC ventilator-associated condition

New and sustained respiratory deterioration

New respiratory deterioration with

concurrent infection

IVAC Infection-related

ventilator-associated complication

Definition: ≥2 days of stable or decreasing daily minimum PEEP or FiO2

followed by

Rise in daily minimum PEEP ≥3 cm H2O sustained ≥2 days or Rise in daily minimum FiO2 ≥20 points sustained ≥2 days

An alternative paradigm for surveillance:

Implemented in NHSN in January 2013

Ventilator Associate Conditions (VAC)

Definition: VAC associated with alterations in WBC (< to 4 or ≥ 12) or temperature (< 36 or ≥ 38o C) within 2 days and Prescription of antibiotics continued ≥ 4 days

An alternative paradigm for surveillance: Infection Related Ventilator Associate Conditions (iVAC)

VAP Guideline Recommendations

• Prevention • Diagnosis • Treatment

Ann Intern Med. 2004;141:305-13. J Crit Care, 2008

• Use Oral Route for intubation May not apply to pts with:

• Maxillofacial trauma/surgery • ENT surgery • Difficult intubation

VAP Guideline Recommendations: Prevention

Sub-glottic Secretion Drainage


Sub-glottic Secretion Drainage

Muscedere et al, CCM 2011

• Subglottic Secretion Drainage • Requirement for prolonged

mechanical ventilation

May not apply to pts with: • Nasally intubation • Tracheostomy tube • Difficult endotracheal intubation


• Semi-recumbent positioning at 45 degree angle

May not apply to pts with:

• Patient on vasopressors or undergoing resuscitation • Spine unstable or not cleared • Pelvic instability or fractures • Prone position • Intra aortic balloon pump • Unable to raise HOB because of obesity • Procedures (includes bathing)


VAP and Semi-recumbency: The evidence

Outcome: The occurrence of VAP

Patient population: • Total of 409 patients studied • Head of bed elevation achieved only

measured in van Nieuwenhoven study

• Chlorhexidine Oral Antiseptic May not apply to pts with:

• Chlorhexidine Allergy • Lack of access to patient’s oral cavity


CHX decontamination compared with no prophylaxis on risk of VAP

VAP Guidelines: Diagnosis

• No improvement in clinical outcomes (mortality, length of stay, antibiotic use) compared to endotracheal aspirate

• May lead to delays in initiation of antibiotic therapy

• Requires expertise, time and personnel without added benefit

Diagnostic Bronchoscopy NOT RECOMMENDED

• Diagnosis of suspected VAP • Endotracheal aspirates with nonquantitative

culture

May not apply to pts with: • Immunocompromised patients at physician’s

discretion

VAP Guideline Recommendations: Diagnosis

Clinical Suspicion of VAP

New or persistent infiltrate on CXR plus 2 of the following: •Purulent endotracheal secretions •Increasing FiO2 requirements •Elevated temperature (> 38.0) •Increased WBC (>11.0) or decreased WBC (<3.5)

Diagnosis of VAP

Endotracheal aspirate

Consider diagnostic bronchoscopy for immunosuppressed patients

VAP Diagnosis

VAP Guidelines: Treatment

Treatment of VAP

• Initial inadequate empiric therapy of VAP is associated with worse outcome

• Delays in therapy associated with worse outcome

ATS Guidelines, 2005

Kuti, JCC 2009

Impact of adequacy of empiric therapy on outcome

Adequate Inadequate p-value*

(n=313) (n=37)

Died within 14 days 33 (10.5%) 9 (24.3%) 0.01

Died within 28 days 51 (16.3%) 12 (32.4%) 0.02

Died in ICU 37 (11.8%) 13 (35.1%) 0.0001

Died in Hospital 61 (19.5%) 18 (48.7%) <0.0001

Muscedere, JCC 2011

• Initiation of empiric treatment for VAP • Start antibiotics at time of VAP

suspicion (do not wait for culture results)

May not apply to pts with: none

VAP Guideline Recommendations: Treatment

• Antibiotics for empiric treatment of VAP • Single effective agent for each suspected

organism May not apply to pts with:

• Patients known to be colonized or previously infected with Pseudomonas sp. or multidrug resistant organisms

• Immunocompromised patients



Monotherapy vs. Combination Therapy: Mortality

• Choice of antibiotics for empiric treatment of VAP

• Based on local ICU resistance patterns and patient factors



• Discontinuation of empiric antibiotics for VAP

• If noninfectious etiology of infiltrates is found

OR • If signs and symptoms of active infection

have resolved



• Choice of Antibiotic for Confirmed VAP

• “A” vs. “B”: No evidence to favor one agent over another – Multiple non-inferiority trials (approx. 30 trials)

• MRSA pneumonia – Linezolid vs. Glycopeptides (Vancomycin)


MRSA VAP Pneumonia

In the three studies • Mortality at different time points reported • No effect on mortality was reported

Clinical cure rate

• Duration of antibiotic treatment for confirmed VAP

• Maximum of 8 days in patients in whom initial empiric therapy was appropriate

May not apply to pts with:

• Immunocompromised patients


TREATMENT OF VAP

•Stop empiric antibiotics for suspected VAP if another reason for patient’s signs & symptoms found •Stop antibiotics for confirmed VAP after 8 days of therapy

Reassess each antibiotic daily based on culture results,

and patient’s signs and symptoms

•Choose antibiotic on the basis of the microbiology and resistance patterns in the ICU •Choose one effective antibiotic active against each potential pathogen

Start empiric antibiotics at the time of clinical suspicion of VAP

Empiric Therapy

Antibiotic Selection

Duration of Antibiotic Therapy

Antibiotic

Management

Thank You

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Canadian ICU Collaborative Faculty

Paule Bernier, P.Dt., Msc, Présidente, Ordre professionnel des diététistes du Québec; Sir MB David Jewish General Hospital (McGill University), Montreal

Paul Boiteau MD, Department Head, Critical Care Medicine, Alberta Health Services; Professor of Medicine, University of Calgary Mike Cass, BSc, RN, MScN, Advanced Practice Nurse, Trillium Health Centre Leanne Couves, Improvement Advisor, Improvement Associates Ltd. Carla Williams, Patient Safety Improvement Lead, CPSI Bruce Harries, Collaborative Director, Improvement Associates Ltd. Denny Laporta MD, Intensivist, Department of Adult Critical Care, Jewish General Hospital; Faculty of Medicine, McGill University Claudio Martin MD,Intensivist, London Health Sciences Centre, Critical Care Trauma Centre; Professor of Medicine and Physiology,

University of Western Ontario; Chair/Chief of Critical Care Western Cathy Mawdsley, RN, MScN, CNCC; Clinical Nurse Specialist – Critical Care, London Health Sciences Centre; John Muscedere MD, Assistant Professor of Medicine, Queens University; Intensivist, Kingston General Hospital Yoanna Skrobik MD, Intensivist, Hôpital Maisonneuve Rosemont, Montréal; Expert Panel for the new Pain, Sedation and Delirium

Guidelines, Society of Critical Care Medline (SCCM)

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recordings will be available on Safer Healthcare Now! Communities of Practice

Additional resources are available on the SHN Website and Communities of Practice

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nationallatest updates to the canadian vap guidelines - what's new?

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