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Hospital-acquired and
Ventilator-associated Pneumonia:
2016 Clinical Practice Guidelines
by the Infectious Diseases Society of America
and the AmericanThoracic Society
Dr. Sandeep Kumar
PG Internal medicine
Sher I Kashmir Institute of Medical Sciences, Soura, Srinagar.
Introduction
• HAP and VAP continue to be frequent complications of hospital care.
Together, they are among the most common hospital-acquired infections
(HAIs), accounting for 22% of all HAIs in a multistate point-prevalence
survey.
• [Magill SS, Edwards JR, Fridkin SK; Emerging Infections Program Healthcare-Associated Infections Antimicrobial Use Prevalence Survey Team. Survey
of healthcare-associated infections. N Engl J Med 2014; 370:2542–3.]
Top 10 causes of death
2005 ATS/IDSA guidelines
Pneumonia* Definition
VAP Patients receiving mechanical ventilation for at least 24 h with first positive bacterial† respiratory
culture finding after ventilator start date.
HAP Patients with a first positive bacterial† respiratory culture finding >2 days from admission who do
not meet VAP definition.
HCAP Patients with a first positive bacterial† respiratory culture finding within 2 days of admission and
any of the following:
(1) admission source indicates a transfer from another health-care facility;
(2)receiving long-term hemodialysis (ICD-9-CMcodes); and
(3) prior hospitalization within 30 days who do not meet VAP definition
CAP Patients with a first positive bacterial† respiratory culture finding who do not meet VAP or HCAP
definition.
 All pneumonia cases with primary or secondary ICD-9-CM codes for pneumonia and positive respiratory culture finding treated in a hospital that collected at least 5 days
of culture data.†Eligible bacteria include: Acinetobacter, Bacillus, Bacteroides, Bordetella,Brucella, Chlamydia, Enterobacter, Escherichia, Haemophilus, Klebsiella,
Legionella, Listeria, MRSA, Mycoplasma, Proteus, Pseudomonas, Salmonella, Serratia, Shigella, S aureus, Streptobacillus, Streptococcus A, Streptococcus B,
Streptococcus C, Streptococcus D, Streptococcus F, Streptococcus G, Streptococcus nongroup, S pneumoniae, Yersinia.(2)
Controversies over HCAP Status
The rationale for inclusion - both the patients’ contact with the healthcare system
and the presumed high risk of MDR pathogens, guidelines for these patients were
included with guidelines for HAP and VAP, the HAPs.
1 – There is increasing evidence from a growing number of studies that many patients
defined as having HCAP are not at high risk for MDR pathogens
{ Chalmers JD, Rother C, Salih W, Ewig S. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a
systematic review and meta-analysis. Clin Infect Dis 2014; 58:330–9.
• Gross AE, Van Schooneveld TC, Olsen KM, et al. Epidemiology and predictors of multidrug-resistant community-acquired and health care-
associated pneumonia. Antimicrob Agents Chemother 2014; 58:5262–8.
• Yap V, Datta D, Metersky ML. Is the present definition of health care-associated pneumonia the best way to define risk of infection with
antibiotic-resistant pathogens? Infect Dis Clin North Am 2013; 27:1–18.
• Jones BE, Jones MM, Huttner B, et al. Trends in antibiotic use and nosocomial pathogens in hospitalized veterans with pneumonia at 128
medical centers,2006–2010. Clin Infect Dis 2015; 61:1403–10.19. Valles J, Martin-Loeches I, Torres A, et al. Epidemiology, antibiotic therapy
and clinical outcomes of healthcare-associated pneumonia in critically ill patients: a Spanish cohort study. Intensive Care Med 2014; 40:572–
81. 15–19.}
HCAP Controversies
2 – Although interaction with the healthcare system is potentially a risk for
MDR pathogens, underlying patient characteristics are also important
independent determinants of risk for MDR pathogens
• Chalmers JD, Rother C, Salih W, Ewig S. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic
review and meta-analysis. Clin Infect Dis 2014; 58:330–9.
• 16. Gross AE, Van Schooneveld TC, Olsen KM, et al. Epidemiology and predictors of multidrug-resistant community-acquired and health care-associated
pneumonia. Antimicrob Agents Chemother 2014; 58:5262–8.
• 17. Yap V, Datta D, Metersky ML. Is the present definition of health care-associated pneumonia the best way to define risk of infection with antibiotic-
resistant pathogens? Infect Dis Clin North Am 2013; 27:1–18.
HCAP to be included in upcoming CAP
guidelines [ATS/IDSA 2016]
• Finally, in light of the more recent data regarding the HCAP population, the panel
anticipated that recommendations regarding coverage for MDR pathogens among
community-dwelling patients who develop pneumonia would likely be based on
validated risk factors for MDR pathogens, not solely on whether or not the patient
had previous contacts with the healthcare system.
•For these reasons, the panel unanimously decided
that HCAP should not be included in the HAP/VAP
guidelines.
HAP/VAP ATS/IDSA 2016 Practice guidelines
• Definition – not amended . Same as 2005 guidelines.
• All recommendations were labeled as either “strong” or “weak” (conditional)
according to the GRADE approach. The words “we recommend” indicate strong
recommendations and “we suggest” indicate weak recommendations.
MICROBIOLOGIC
METHODS TO DIAGNOSE
VAP ANDHAP
Threshold values for cultured specimens used in the
diagnosis of pneumonia
Specimen collection/technique Values†
Lung tissue >104 CFU/g tissue
Bronchoscopically (B) obtained specimens
Bronchoalveolar lavage (B-BAL) >104 CFU/ml
Protected BAL (B-PBAL) >104 CFU/ml
Protected specimen brushing (B-PSB) >103 CFU/ml
Nonbronchoscopically (NB) obtained (blind) specimens
NB-BAL >104 CFU/ml
NB-PSB >103 CFU/ml†CFU = colony forming units, g = gram, ml = milliliter
CDC/NHSN Pneumonia (Ventilator-associated [VAP] and non-ventilator-associated Pneumonia [PNEU]) Event. January 2015, modified April 2015.
Should Patients With Suspected VAP Be Treated Based on the Results of Invasive Sampling (i.e,
Bronchoscopy, Blind Bronchial Sampling) With Quantitative Culture Results, Non-invasive Sampling
(i.e, Endotracheal Aspiration) With Quantitative Culture Results, or Non-invasive Sampling With Semi-
quantitative Culture Results?
• Non-invasive sampling with semi-quantitative cultures to diagnose VAP, (weak
recommendation, low-quality evidence).
• Remarks: Invasive respiratory sampling includes bronchoscopic techniques (ie,
bronchoalveolar lavage [BAL], protected specimen brush [PSB]) and blind
bronchial sampling (ie, mini-BAL). Noninvasive respiratory sampling refers to
endotracheal aspiration.
If Invasive Quantitative Cultures Are Performed, Should Patients With Suspected VAP Whose
Culture Results Are Below the Diagnostic Threshold for VAP (PSB With <103 Colony-
Forming Units [CFU]/mL, BAL With <104 CFU/mL) Have Their Antibiotics Withheld Rather
Than Continued?
Antibiotics be withheld rather than continued (weak recommendation, very low-quality
evidence).
• Values and Preferences: Avoiding unnecessary harm and cost.
• Remarks: Clinical factors should also be considered because they may alter the decision of
whether to withhold or continue antibiotics.
These include the
- Likelihood of an alternative source of infection,
- Prior antimicrobial therapy at the time of culture,
- Degree of clinical suspicion,
- Signs of severe sepsis, and
- Evidence of clinical improvement.
In Patients With Suspected HAP (Non-VAP), Should Treatment Be Guided by
the Results of Microbiologic Studies Performed on Respiratory Samples, or
Should Treatment Be Empiric?
Treat according to the results of microbiologic studies performed on respiratory samples obtained
noninvasively, rather than being treated empirically (weak recommendation, very low-quality
evidence).
Values and Preferences: The suggestion places a high value on the potential to accurately target
antibiotic therapy and then deescalate antibiotic therapy based upon respiratory and blood culture
results. Minimizing resource use by not obtaining respiratory cultures is given a lower value.
Remarks: Non-invasive methods to obtain respiratory samples include the following:
• spontaneous expectoration,
• sputum induction,
• naso-tracheal suctioning in a patient who is unable to cooperate to produce a sputum sample,
and
• endotracheal aspiration in a patient with HAP who subsequently requires mechanical
ventilation.
The panel recognizes that for some patients in whom a respiratory sample cannot be obtained
noninvasively, there may be factors which could prompt consideration of obtaining samples
invasively.
THE USE OF BIOMARKERS AND THE CLINICAL
PULMONARY INFECTION SCORE [CPIS] TO
DIAGNOSE
VAP AND HAP
In Patients With Suspected HAP/VAP, Should Procalcitonin (PCT)
Plus Clinical Criteria or Clinical Criteria Alone Be Used to Decide
Whether or Not to Initiate Antibiotic Therapy?
• Using clinical criteria alone, rather than using serum PCT plus clinical
criteria, to decide whether or not to initiate antibiotic therapy (strong
recommendation, moderate-quality evidence).
In Patients With Suspected HAP/VAP, Should Soluble Triggering
Receptor Expressed on Myeloid Cells (sTREM-1) Plus Clinical Criteria
or Clinical Criteria Alone Be Used to Decide Whether or Not to Initiate
Antibiotic Therapy?
• Using clinical criteria alone, rather than using broncho-alveolar lavage fluid
(BALF) sTREM-1 plus clinical criteria, to decide whether or not to initiate
antibiotic therapy (strong recommendation, moderate-quality evidence).
In Patients With Suspected HAP/VAP, Should C-Reactive Protein
(CRP) Plus Clinical Criteria, or Clinical Criteria Alone, Be Used to
Decide Whether or Not to Initiate Antibiotic Therapy?
• Using clinical criteria alone rather than using CRP plus clinical criteria, to decide
whether or not to initiate antibiotic therapy (weak recommendation, low-quality
evidence).
In Patients With Suspected HAP/VAP, Should the Modified Clinical Pulmonary
Infection Score (CPIS) Plus Clinical Criteria, or Clinical Criteria Alone, Be Used to
Decide Whether or Not to Initiate Antibiotic Therapy?
Using clinical criteria alone, rather than using CPIS plus clinical criteria, to
decide whether or not to initiate antibiotic therapy (weak recommendation, low-
quality evidence).
Clinical Pulmonary Infection Score Calculation.
Marya D. Zilberberg, and Andrew F. Shorr Clin Infect Dis.
2010;51:S131-S135
© 2010 by the Infectious Diseases Society of America
CDC/NHSN Pneumonia (Ventilator-associated [VAP] and non-ventilator-associated Pneumonia
[PNEU]) Event. January 2015, modified April 2015.
TREATMENT OF
VENTILATOR-ASSOCIATED
TRACHEOBRONCHITIS
Should Patients With Ventilator-Associated
Tracheo-bronchitis (VAT) Receive
Antibiotic Therapy?
• Not providing antibiotic therapy (weak recommendation, low-
quality evidence).
INITIAL TREATMENT
OF VAP AND HAP
Should Selection of an Empiric Antibiotic Regimen for VAP
Be Guided by Local Antibiotic-Resistance Data?
• All hospitals regularly generate and disseminate a local antibiogram, ideally one that is specific
to their intensive care population(s) if possible
• Empiric treatment regimens be informed by the local distribution of pathogens associated with
VAP and their antimicrobial susceptibilities.
• Values and preferences: Targeting the specific pathogens and to assure adequate treatment.
• Remarks: The frequency with which the distribution of pathogens and their antimicrobial
susceptibilities are updated should be determined by the institution. Considerations should
include their rate of change, resources, and the amount of data available for analysis.
What Antibiotics Are Recommended for Empiric
Treatment of Clinically Suspected VAP?
• Coverage for S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli in all empiric regimens (strong
recommendation, low-quality evidence).
• i.We suggest including an agent active against MRSA for the empiric treatment of suspectedVAP only in patients
with any of the following:
• a risk factor for antimicrobial resistance (Table 2),
• patients being treated in units where >10%–20% of S. aureus isolates are methicillin resistant, and
• patients in units where the prevalence of MRSA is not known (weak recommendation, very low-quality evidence).
• ii. We suggest including an agent active against methicillin sensitive S. aureus (MSSA) (and not MRSA) for the
empiric treatment of suspectedVAP in patients without risk factors for antimicrobial resistance, who are being
treated in ICUs where <10%–20% of S. aureus isolates are methicillin resistant (weak recommendation, very low-
quality evidence).
• 2. If empiric coverage for MRSA - vancomycin or linezolid (strong recommendation, moderate-quality evidence).
• 3. empiric coverage for MSSA (and not MRSA) - piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or
meropenem (weak recommendation, very low-quality evidence). Oxacillin, nafcillin, or cefazolin are preferred
agents for treatment of proven MSSA, but are not necessary for the empiric treatment ofVAP if one of the above
agents is used.
• 4. Two antipseudomonal antibiotics from different classes for the empiric treatment of
suspected VAP only in patients with any of the following:
• a risk factor for antimicrobial resistance,
• patients in units where >10% of gram-negative isolates are resistant to an agent being
considered for monotherapy, and
• patients in an ICU where local antimicrobial susceptibility rates are not available
(weak recommendation, low-quality evidence).
• 5. We suggest prescribing one antibiotic active against P. aeruginosa for the empiric
treatment of suspected VAP in patients without risk factors for antimicrobial resistance
who are being treated in ICUs where ≤10% of gram-negative isolates are resistant to
the agent being considered for monotherapy (weak recommendation, low-quality
evidence).
• 6. In patients with suspected VAP, we suggest avoiding Colistin / aminoglycosides if alternative
agents with adequate gram-negative activity are available (weak recommendation, low-quality
evidence).
• Values and Preferences: These recommendations are a compromise between the competing goals
of providing early appropriate antibiotic coverage and avoiding superfluous treatment that may
lead to adverse drug effects, Clostridium difficile infections, antibiotic resistance, and increased
cost.
• Remarks: The 10%–20% threshold for deciding whether or not to target MRSA and the 10%
threshold for deciding whether or not to prescribe 1 antipseudomonal agent or 2 were chosen by
the panel with a goal of trying to assure that ≥95% of patient receive empiric therapy active
against their likely pathogens; when implementing these recommendations, individual ICUs may
elect to modify these thresholds.
• If patient has structural lung disease increasing the risk of gram-negative infection (ie,
bronchiectasis or cystic fibrosis), 2 antipseudomonal agents are recommended.
HAP/VAP 2016 ATS/IDSA Guidelines. Our Data available at: https://rdcu.be/Mx8E
HAP/VAP 2016 ATS/IDSA Guidelines. Our Data available at: https://rdcu.be/Mx8E
HAP/VAP 2016 ATS/IDSA Guidelines. Our Data available at: https://rdcu.be/Mx8E
PHARMACOKINETIC / PHARMACODYNAMIC
OPTIMIZATION OF ANTIBIOTIC THERAPY
Should Antibiotic Dosing Be Determined by
Pharmacokinetic/Pharmacodynamic (PK/PD) Data or the Manufacturer’s
Prescribing Information in Patients With HAP/VAP?
• Antibiotic dosing be determined using PK/PD data, rather than the
manufacturer’s prescribing information (weak recommendation, very low-
quality evidence).
ROLE OF INHALED ANTIBIOTIC
THERAPY
• For patients with VAP due to gram-negative bacilli that are susceptible to
only aminoglycosides or polymyxins (Colistin or polymyxin B), we suggest
both inhaled and systemic antibiotics, rather than systemic antibiotics alone
(weak recommendation, very low-quality evidence).
• Values and Preferences: This recommendation places a high value on
achieving clinical cure and survival; it places a lower value on burden and
cost.
• Remarks: It is reasonable to consider adjunctive inhaled antibiotic therapy as
a treatment of last resort for patients who are not responding to intravenous
antibiotics alone, whether the infecting organism is or is not multidrug
resistant (MDR).
PATHOGEN-SPECIFIC
THERAPY
What Antibiotics Should Be Used for the
Treatment for MRSA HAP/VAP?
• Treat with either vancomycin or linezolid rather than other antibiotics or
antibiotic combinations (strong recommendation, moderate- quality
evidence).
• Remarks: The choice between vancomycin and linezolid may be guided by
patient-specific factors such as blood cell counts, concurrent
prescriptions for serotonin-reuptake inhibitors,
renal function, and cost.
Which Antibiotic Should Be Used to Treat
Patients With HAP/VAP due to P. aeruginosa?
• The choice of an antibiotic for definitive (not empiric) therapy be based upon
the results of antimicrobial susceptibility testing (strong recommendation,
low-quality evidence).
• Recommendation is against aminoglycoside monotherapy (strong
recommendation, very low-quality evidence).
• Remarks: Routine antimicrobial susceptibility testing should include
assessment of the sensitivity of the P. aeruginosa isolate to polymyxins
(colistin or polymyxin B) in settings that have a high prevalence of
extensively resistant organisms.
Should Monotherapy or Combination Therapy Be
Used to Treat Patients With HAP/VAP Due to
P. aeruginosa?
• 1. Not in septic shock or at a high risk for death, and for whom the results of antibiotic susceptibility
testing are known, we recommend monotherapy using an antibiotic to which the isolate is susceptible
rather than combination therapy (strong recommendation, low-quality evidence).
• 2. Who remain in septic shock or at a high risk for death when the results of antibiotic susceptibility testing
are known, we suggest combination therapy using 2 antibiotics to which the isolate is susceptible rather
than monotherapy (weak recommendation, very low-quality evidence).
• 3. For patients with HAP/VAP due to P. aeruginosa, we recommend against aminoglycoside monotherapy
(strong recommendation, very low-quality evidence).
• Remarks: High risk of death in the meta-regression analysis was defined as mortality risk >25%; low risk
of death is defined as mortality risk <15%.
• For a patient whose septic shock resolves when antimicrobial sensitivities are known, continued
combination therapy is not recommended.
Which Antibiotic Should Be Used to Treat Patients With HAP/VAP Due to
Extended-Spectrum β-Lactamase (ESBL)–Producing Gram- Negative Bacilli?
• Choice of an antibiotic for definitive (not empiric) therapy be based upon the results
of antimicrobial susceptibility testing and patient-specific factors (strong
recommendation, very low-quality evidence).
• Remarks: Patient-specific factors that should be considered when selecting an
antimicrobial agent include allergies and comorbidities that may confer an increased
risk of side effects.
Which Antibiotic Should Be Used to Treat Patients With HAP/VAP
Due to Acinetobacter Species?
• 1. Treatment with either a carbapenem or ampicillin/ sulbactam if the isolate is susceptible to these agents
(weak recommendation, low-quality evidence).
• 2. Sensitive only to polymyxins, use IV polymyxin (colistin or polymyxin B) (strong recommendation,
low-quality evidence), and we suggest adjunctive inhaled colistin (weak recommendation, low-quality
evidence).
• 3. Sensitive only to colistin, we suggest not using adjunctive rifampicin (weak recommendation,
moderate-quality evidence).
• 4. Guidelines recommend against the use of tigecycline (strong recommendation, low-quality evidence).
• Values and Preferences: Avoiding potential adverse effects due to the use of combination therapy with
Rifampicin and colistin, over achieving an increased microbial eradication rate, as eradication rate was
not associated with improved clinical outcome.
• Remarks: Selection of an appropriate antibiotic for definitive (nonempiric) therapy requires antimicrobial
susceptibility testing.
Which Antibiotic Should Be Used to Treat Patients With
HAP/VAP Due to Carbapenem-Resistant Pathogens?
• Sensitive only to polymyxins, use Intravenous polymyxins (colistin or polymyxin B) (strong
recommendation, moderate-quality evidence), and we suggest adjunctive inhaled colistin (weak
recommendation, low-quality evidence).
• Values and Preferences: Higher value on Achieving clinical cure and survival; they place a
lower value on burden and cost.
• Remarks: Inhaled colistin may have potential pharmacokinetic advantages compared to inhaled
polymyxin B, and clinical evidence based on controlled studies has also shown that inhaled
colistin may be associated with improved clinical outcomes.
• The clinical evidence for inhaled Polymyxin B is mostly from anecdotal and uncontrolled
studies; we are therefore not suggesting use of inhaled Polymyxin B.
• Colistin for inhalation should be administered promptly after being mixed with sterile water.
This recommendation was made by the US Food and Drug Administration (FDA) after a report
that a cystic fibrosis patient died after being treated with a premixed colistin formulation.
LENGTH OFTHERAPY
Should Patients With VAP Receive 7 Days
or 8–15 Days of Antibiotic Therapy?
• 1. For patients with VAP, we recommend a 7-day course of antimicrobial therapy
rather than a longer duration (strong recommendation, moderate-quality evidence).
• Remarks: There exist situations in which a shorter or longer duration of antibiotics
may be indicated, depending upon the rate of improvement of clinical, radiologic,
and laboratory parameters.
What Is the Optimal Duration of Antibiotic
Therapy for HAP (Non-VAP)?
• 7-day course of antimicrobial therapy (strong recommendation, very low quality
evidence).
• Remarks: There exist situations in which a shorter or longer duration of antibiotics
may be indicated, depending upon the rate of improvement of clinical, radiologic,
and laboratory parameters.
Should Antibiotic Therapy Be De-escalated or
Fixed in Patients With HAP/VAP?
• Antibiotic therapy be de-escalated rather than fixed (weak recommendation, very
low-quality evidence).
• Remarks: De-escalation refers to changing an empiric broad-spectrum antibiotic
regimen to a narrower antibiotic regimen by changing the antimicrobial agent or
changing from combination therapy to monotherapy.
• In contrast, fixed antibiotic therapy refers to maintaining a broad-spectrum
antibiotic regimen until therapy is completed.
Should Discontinuation of Antibiotic Therapy Be Based
Upon PCT Levels Plus Clinical Criteria or Clinical Criteria
Alone in Patients With HAP/VAP?
• Using PCT levels plus clinical criteria to guide the discontinuation of antibiotic
therapy, rather than clinical criteria alone (weak recommendation, low-quality
evidence).
• Remarks: It is not known if the benefits of using PCT levels to determine whether or
not to discontinue antibiotic therapy exist in settings where standard antimicrobial
therapy for VAP is already 7 days or less.
Should Discontinuation of Antibiotic Therapy Be Based
Upon the CPIS Plus Clinical Criteria or Clinical Criteria
Alone in Patients With Suspected HAP/VAP?
Not using the CPIS to guide the discontinuation of antibiotic
therapy (weak recommendation, low-quality evidence).
• Do the difficult things while they are easy and do the great things while they are small. A journey of a
thousand miles must begin with a single step.
-Lao Tzu.
“If you are irritated by every rub, how will your mirror be polished?”
― Rumi

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HAP/VAP 2016 ATS/IDSA Guidelines. Our Data available at: https://rdcu.be/Mx8E

  • 1. Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the AmericanThoracic Society Dr. Sandeep Kumar PG Internal medicine Sher I Kashmir Institute of Medical Sciences, Soura, Srinagar.
  • 2. Introduction • HAP and VAP continue to be frequent complications of hospital care. Together, they are among the most common hospital-acquired infections (HAIs), accounting for 22% of all HAIs in a multistate point-prevalence survey. • [Magill SS, Edwards JR, Fridkin SK; Emerging Infections Program Healthcare-Associated Infections Antimicrobial Use Prevalence Survey Team. Survey of healthcare-associated infections. N Engl J Med 2014; 370:2542–3.]
  • 3. Top 10 causes of death
  • 4. 2005 ATS/IDSA guidelines Pneumonia* Definition VAP Patients receiving mechanical ventilation for at least 24 h with first positive bacterial† respiratory culture finding after ventilator start date. HAP Patients with a first positive bacterial† respiratory culture finding >2 days from admission who do not meet VAP definition. HCAP Patients with a first positive bacterial† respiratory culture finding within 2 days of admission and any of the following: (1) admission source indicates a transfer from another health-care facility; (2)receiving long-term hemodialysis (ICD-9-CMcodes); and (3) prior hospitalization within 30 days who do not meet VAP definition CAP Patients with a first positive bacterial† respiratory culture finding who do not meet VAP or HCAP definition.  All pneumonia cases with primary or secondary ICD-9-CM codes for pneumonia and positive respiratory culture finding treated in a hospital that collected at least 5 days of culture data.†Eligible bacteria include: Acinetobacter, Bacillus, Bacteroides, Bordetella,Brucella, Chlamydia, Enterobacter, Escherichia, Haemophilus, Klebsiella, Legionella, Listeria, MRSA, Mycoplasma, Proteus, Pseudomonas, Salmonella, Serratia, Shigella, S aureus, Streptobacillus, Streptococcus A, Streptococcus B, Streptococcus C, Streptococcus D, Streptococcus F, Streptococcus G, Streptococcus nongroup, S pneumoniae, Yersinia.(2)
  • 5. Controversies over HCAP Status The rationale for inclusion - both the patients’ contact with the healthcare system and the presumed high risk of MDR pathogens, guidelines for these patients were included with guidelines for HAP and VAP, the HAPs. 1 – There is increasing evidence from a growing number of studies that many patients defined as having HCAP are not at high risk for MDR pathogens { Chalmers JD, Rother C, Salih W, Ewig S. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis. Clin Infect Dis 2014; 58:330–9. • Gross AE, Van Schooneveld TC, Olsen KM, et al. Epidemiology and predictors of multidrug-resistant community-acquired and health care- associated pneumonia. Antimicrob Agents Chemother 2014; 58:5262–8. • Yap V, Datta D, Metersky ML. Is the present definition of health care-associated pneumonia the best way to define risk of infection with antibiotic-resistant pathogens? Infect Dis Clin North Am 2013; 27:1–18. • Jones BE, Jones MM, Huttner B, et al. Trends in antibiotic use and nosocomial pathogens in hospitalized veterans with pneumonia at 128 medical centers,2006–2010. Clin Infect Dis 2015; 61:1403–10.19. Valles J, Martin-Loeches I, Torres A, et al. Epidemiology, antibiotic therapy and clinical outcomes of healthcare-associated pneumonia in critically ill patients: a Spanish cohort study. Intensive Care Med 2014; 40:572– 81. 15–19.}
  • 6. HCAP Controversies 2 – Although interaction with the healthcare system is potentially a risk for MDR pathogens, underlying patient characteristics are also important independent determinants of risk for MDR pathogens • Chalmers JD, Rother C, Salih W, Ewig S. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis. Clin Infect Dis 2014; 58:330–9. • 16. Gross AE, Van Schooneveld TC, Olsen KM, et al. Epidemiology and predictors of multidrug-resistant community-acquired and health care-associated pneumonia. Antimicrob Agents Chemother 2014; 58:5262–8. • 17. Yap V, Datta D, Metersky ML. Is the present definition of health care-associated pneumonia the best way to define risk of infection with antibiotic- resistant pathogens? Infect Dis Clin North Am 2013; 27:1–18.
  • 7. HCAP to be included in upcoming CAP guidelines [ATS/IDSA 2016] • Finally, in light of the more recent data regarding the HCAP population, the panel anticipated that recommendations regarding coverage for MDR pathogens among community-dwelling patients who develop pneumonia would likely be based on validated risk factors for MDR pathogens, not solely on whether or not the patient had previous contacts with the healthcare system. •For these reasons, the panel unanimously decided that HCAP should not be included in the HAP/VAP guidelines.
  • 8. HAP/VAP ATS/IDSA 2016 Practice guidelines • Definition – not amended . Same as 2005 guidelines. • All recommendations were labeled as either “strong” or “weak” (conditional) according to the GRADE approach. The words “we recommend” indicate strong recommendations and “we suggest” indicate weak recommendations.
  • 10. Threshold values for cultured specimens used in the diagnosis of pneumonia Specimen collection/technique Values† Lung tissue >104 CFU/g tissue Bronchoscopically (B) obtained specimens Bronchoalveolar lavage (B-BAL) >104 CFU/ml Protected BAL (B-PBAL) >104 CFU/ml Protected specimen brushing (B-PSB) >103 CFU/ml Nonbronchoscopically (NB) obtained (blind) specimens NB-BAL >104 CFU/ml NB-PSB >103 CFU/ml†CFU = colony forming units, g = gram, ml = milliliter CDC/NHSN Pneumonia (Ventilator-associated [VAP] and non-ventilator-associated Pneumonia [PNEU]) Event. January 2015, modified April 2015.
  • 11. Should Patients With Suspected VAP Be Treated Based on the Results of Invasive Sampling (i.e, Bronchoscopy, Blind Bronchial Sampling) With Quantitative Culture Results, Non-invasive Sampling (i.e, Endotracheal Aspiration) With Quantitative Culture Results, or Non-invasive Sampling With Semi- quantitative Culture Results? • Non-invasive sampling with semi-quantitative cultures to diagnose VAP, (weak recommendation, low-quality evidence). • Remarks: Invasive respiratory sampling includes bronchoscopic techniques (ie, bronchoalveolar lavage [BAL], protected specimen brush [PSB]) and blind bronchial sampling (ie, mini-BAL). Noninvasive respiratory sampling refers to endotracheal aspiration.
  • 12. If Invasive Quantitative Cultures Are Performed, Should Patients With Suspected VAP Whose Culture Results Are Below the Diagnostic Threshold for VAP (PSB With <103 Colony- Forming Units [CFU]/mL, BAL With <104 CFU/mL) Have Their Antibiotics Withheld Rather Than Continued? Antibiotics be withheld rather than continued (weak recommendation, very low-quality evidence). • Values and Preferences: Avoiding unnecessary harm and cost. • Remarks: Clinical factors should also be considered because they may alter the decision of whether to withhold or continue antibiotics. These include the - Likelihood of an alternative source of infection, - Prior antimicrobial therapy at the time of culture, - Degree of clinical suspicion, - Signs of severe sepsis, and - Evidence of clinical improvement.
  • 13. In Patients With Suspected HAP (Non-VAP), Should Treatment Be Guided by the Results of Microbiologic Studies Performed on Respiratory Samples, or Should Treatment Be Empiric? Treat according to the results of microbiologic studies performed on respiratory samples obtained noninvasively, rather than being treated empirically (weak recommendation, very low-quality evidence). Values and Preferences: The suggestion places a high value on the potential to accurately target antibiotic therapy and then deescalate antibiotic therapy based upon respiratory and blood culture results. Minimizing resource use by not obtaining respiratory cultures is given a lower value. Remarks: Non-invasive methods to obtain respiratory samples include the following: • spontaneous expectoration, • sputum induction, • naso-tracheal suctioning in a patient who is unable to cooperate to produce a sputum sample, and • endotracheal aspiration in a patient with HAP who subsequently requires mechanical ventilation. The panel recognizes that for some patients in whom a respiratory sample cannot be obtained noninvasively, there may be factors which could prompt consideration of obtaining samples invasively.
  • 14. THE USE OF BIOMARKERS AND THE CLINICAL PULMONARY INFECTION SCORE [CPIS] TO DIAGNOSE VAP AND HAP
  • 15. In Patients With Suspected HAP/VAP, Should Procalcitonin (PCT) Plus Clinical Criteria or Clinical Criteria Alone Be Used to Decide Whether or Not to Initiate Antibiotic Therapy? • Using clinical criteria alone, rather than using serum PCT plus clinical criteria, to decide whether or not to initiate antibiotic therapy (strong recommendation, moderate-quality evidence).
  • 16. In Patients With Suspected HAP/VAP, Should Soluble Triggering Receptor Expressed on Myeloid Cells (sTREM-1) Plus Clinical Criteria or Clinical Criteria Alone Be Used to Decide Whether or Not to Initiate Antibiotic Therapy? • Using clinical criteria alone, rather than using broncho-alveolar lavage fluid (BALF) sTREM-1 plus clinical criteria, to decide whether or not to initiate antibiotic therapy (strong recommendation, moderate-quality evidence).
  • 17. In Patients With Suspected HAP/VAP, Should C-Reactive Protein (CRP) Plus Clinical Criteria, or Clinical Criteria Alone, Be Used to Decide Whether or Not to Initiate Antibiotic Therapy? • Using clinical criteria alone rather than using CRP plus clinical criteria, to decide whether or not to initiate antibiotic therapy (weak recommendation, low-quality evidence).
  • 18. In Patients With Suspected HAP/VAP, Should the Modified Clinical Pulmonary Infection Score (CPIS) Plus Clinical Criteria, or Clinical Criteria Alone, Be Used to Decide Whether or Not to Initiate Antibiotic Therapy? Using clinical criteria alone, rather than using CPIS plus clinical criteria, to decide whether or not to initiate antibiotic therapy (weak recommendation, low- quality evidence).
  • 19. Clinical Pulmonary Infection Score Calculation. Marya D. Zilberberg, and Andrew F. Shorr Clin Infect Dis. 2010;51:S131-S135 © 2010 by the Infectious Diseases Society of America
  • 20. CDC/NHSN Pneumonia (Ventilator-associated [VAP] and non-ventilator-associated Pneumonia [PNEU]) Event. January 2015, modified April 2015.
  • 22. Should Patients With Ventilator-Associated Tracheo-bronchitis (VAT) Receive Antibiotic Therapy? • Not providing antibiotic therapy (weak recommendation, low- quality evidence).
  • 24. Should Selection of an Empiric Antibiotic Regimen for VAP Be Guided by Local Antibiotic-Resistance Data? • All hospitals regularly generate and disseminate a local antibiogram, ideally one that is specific to their intensive care population(s) if possible • Empiric treatment regimens be informed by the local distribution of pathogens associated with VAP and their antimicrobial susceptibilities. • Values and preferences: Targeting the specific pathogens and to assure adequate treatment. • Remarks: The frequency with which the distribution of pathogens and their antimicrobial susceptibilities are updated should be determined by the institution. Considerations should include their rate of change, resources, and the amount of data available for analysis.
  • 25. What Antibiotics Are Recommended for Empiric Treatment of Clinically Suspected VAP? • Coverage for S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli in all empiric regimens (strong recommendation, low-quality evidence). • i.We suggest including an agent active against MRSA for the empiric treatment of suspectedVAP only in patients with any of the following: • a risk factor for antimicrobial resistance (Table 2), • patients being treated in units where >10%–20% of S. aureus isolates are methicillin resistant, and • patients in units where the prevalence of MRSA is not known (weak recommendation, very low-quality evidence). • ii. We suggest including an agent active against methicillin sensitive S. aureus (MSSA) (and not MRSA) for the empiric treatment of suspectedVAP in patients without risk factors for antimicrobial resistance, who are being treated in ICUs where <10%–20% of S. aureus isolates are methicillin resistant (weak recommendation, very low- quality evidence). • 2. If empiric coverage for MRSA - vancomycin or linezolid (strong recommendation, moderate-quality evidence). • 3. empiric coverage for MSSA (and not MRSA) - piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem (weak recommendation, very low-quality evidence). Oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven MSSA, but are not necessary for the empiric treatment ofVAP if one of the above agents is used.
  • 26. • 4. Two antipseudomonal antibiotics from different classes for the empiric treatment of suspected VAP only in patients with any of the following: • a risk factor for antimicrobial resistance, • patients in units where >10% of gram-negative isolates are resistant to an agent being considered for monotherapy, and • patients in an ICU where local antimicrobial susceptibility rates are not available (weak recommendation, low-quality evidence). • 5. We suggest prescribing one antibiotic active against P. aeruginosa for the empiric treatment of suspected VAP in patients without risk factors for antimicrobial resistance who are being treated in ICUs where ≤10% of gram-negative isolates are resistant to the agent being considered for monotherapy (weak recommendation, low-quality evidence).
  • 27. • 6. In patients with suspected VAP, we suggest avoiding Colistin / aminoglycosides if alternative agents with adequate gram-negative activity are available (weak recommendation, low-quality evidence). • Values and Preferences: These recommendations are a compromise between the competing goals of providing early appropriate antibiotic coverage and avoiding superfluous treatment that may lead to adverse drug effects, Clostridium difficile infections, antibiotic resistance, and increased cost. • Remarks: The 10%–20% threshold for deciding whether or not to target MRSA and the 10% threshold for deciding whether or not to prescribe 1 antipseudomonal agent or 2 were chosen by the panel with a goal of trying to assure that ≥95% of patient receive empiric therapy active against their likely pathogens; when implementing these recommendations, individual ICUs may elect to modify these thresholds. • If patient has structural lung disease increasing the risk of gram-negative infection (ie, bronchiectasis or cystic fibrosis), 2 antipseudomonal agents are recommended.
  • 32. Should Antibiotic Dosing Be Determined by Pharmacokinetic/Pharmacodynamic (PK/PD) Data or the Manufacturer’s Prescribing Information in Patients With HAP/VAP? • Antibiotic dosing be determined using PK/PD data, rather than the manufacturer’s prescribing information (weak recommendation, very low- quality evidence).
  • 33. ROLE OF INHALED ANTIBIOTIC THERAPY • For patients with VAP due to gram-negative bacilli that are susceptible to only aminoglycosides or polymyxins (Colistin or polymyxin B), we suggest both inhaled and systemic antibiotics, rather than systemic antibiotics alone (weak recommendation, very low-quality evidence). • Values and Preferences: This recommendation places a high value on achieving clinical cure and survival; it places a lower value on burden and cost. • Remarks: It is reasonable to consider adjunctive inhaled antibiotic therapy as a treatment of last resort for patients who are not responding to intravenous antibiotics alone, whether the infecting organism is or is not multidrug resistant (MDR).
  • 35. What Antibiotics Should Be Used for the Treatment for MRSA HAP/VAP? • Treat with either vancomycin or linezolid rather than other antibiotics or antibiotic combinations (strong recommendation, moderate- quality evidence). • Remarks: The choice between vancomycin and linezolid may be guided by patient-specific factors such as blood cell counts, concurrent prescriptions for serotonin-reuptake inhibitors, renal function, and cost.
  • 36. Which Antibiotic Should Be Used to Treat Patients With HAP/VAP due to P. aeruginosa? • The choice of an antibiotic for definitive (not empiric) therapy be based upon the results of antimicrobial susceptibility testing (strong recommendation, low-quality evidence). • Recommendation is against aminoglycoside monotherapy (strong recommendation, very low-quality evidence). • Remarks: Routine antimicrobial susceptibility testing should include assessment of the sensitivity of the P. aeruginosa isolate to polymyxins (colistin or polymyxin B) in settings that have a high prevalence of extensively resistant organisms.
  • 37. Should Monotherapy or Combination Therapy Be Used to Treat Patients With HAP/VAP Due to P. aeruginosa? • 1. Not in septic shock or at a high risk for death, and for whom the results of antibiotic susceptibility testing are known, we recommend monotherapy using an antibiotic to which the isolate is susceptible rather than combination therapy (strong recommendation, low-quality evidence). • 2. Who remain in septic shock or at a high risk for death when the results of antibiotic susceptibility testing are known, we suggest combination therapy using 2 antibiotics to which the isolate is susceptible rather than monotherapy (weak recommendation, very low-quality evidence). • 3. For patients with HAP/VAP due to P. aeruginosa, we recommend against aminoglycoside monotherapy (strong recommendation, very low-quality evidence). • Remarks: High risk of death in the meta-regression analysis was defined as mortality risk >25%; low risk of death is defined as mortality risk <15%. • For a patient whose septic shock resolves when antimicrobial sensitivities are known, continued combination therapy is not recommended.
  • 38. Which Antibiotic Should Be Used to Treat Patients With HAP/VAP Due to Extended-Spectrum β-Lactamase (ESBL)–Producing Gram- Negative Bacilli? • Choice of an antibiotic for definitive (not empiric) therapy be based upon the results of antimicrobial susceptibility testing and patient-specific factors (strong recommendation, very low-quality evidence). • Remarks: Patient-specific factors that should be considered when selecting an antimicrobial agent include allergies and comorbidities that may confer an increased risk of side effects.
  • 39. Which Antibiotic Should Be Used to Treat Patients With HAP/VAP Due to Acinetobacter Species? • 1. Treatment with either a carbapenem or ampicillin/ sulbactam if the isolate is susceptible to these agents (weak recommendation, low-quality evidence). • 2. Sensitive only to polymyxins, use IV polymyxin (colistin or polymyxin B) (strong recommendation, low-quality evidence), and we suggest adjunctive inhaled colistin (weak recommendation, low-quality evidence). • 3. Sensitive only to colistin, we suggest not using adjunctive rifampicin (weak recommendation, moderate-quality evidence). • 4. Guidelines recommend against the use of tigecycline (strong recommendation, low-quality evidence). • Values and Preferences: Avoiding potential adverse effects due to the use of combination therapy with Rifampicin and colistin, over achieving an increased microbial eradication rate, as eradication rate was not associated with improved clinical outcome. • Remarks: Selection of an appropriate antibiotic for definitive (nonempiric) therapy requires antimicrobial susceptibility testing.
  • 40. Which Antibiotic Should Be Used to Treat Patients With HAP/VAP Due to Carbapenem-Resistant Pathogens? • Sensitive only to polymyxins, use Intravenous polymyxins (colistin or polymyxin B) (strong recommendation, moderate-quality evidence), and we suggest adjunctive inhaled colistin (weak recommendation, low-quality evidence). • Values and Preferences: Higher value on Achieving clinical cure and survival; they place a lower value on burden and cost. • Remarks: Inhaled colistin may have potential pharmacokinetic advantages compared to inhaled polymyxin B, and clinical evidence based on controlled studies has also shown that inhaled colistin may be associated with improved clinical outcomes. • The clinical evidence for inhaled Polymyxin B is mostly from anecdotal and uncontrolled studies; we are therefore not suggesting use of inhaled Polymyxin B. • Colistin for inhalation should be administered promptly after being mixed with sterile water. This recommendation was made by the US Food and Drug Administration (FDA) after a report that a cystic fibrosis patient died after being treated with a premixed colistin formulation.
  • 42. Should Patients With VAP Receive 7 Days or 8–15 Days of Antibiotic Therapy? • 1. For patients with VAP, we recommend a 7-day course of antimicrobial therapy rather than a longer duration (strong recommendation, moderate-quality evidence). • Remarks: There exist situations in which a shorter or longer duration of antibiotics may be indicated, depending upon the rate of improvement of clinical, radiologic, and laboratory parameters.
  • 43. What Is the Optimal Duration of Antibiotic Therapy for HAP (Non-VAP)? • 7-day course of antimicrobial therapy (strong recommendation, very low quality evidence). • Remarks: There exist situations in which a shorter or longer duration of antibiotics may be indicated, depending upon the rate of improvement of clinical, radiologic, and laboratory parameters.
  • 44. Should Antibiotic Therapy Be De-escalated or Fixed in Patients With HAP/VAP? • Antibiotic therapy be de-escalated rather than fixed (weak recommendation, very low-quality evidence). • Remarks: De-escalation refers to changing an empiric broad-spectrum antibiotic regimen to a narrower antibiotic regimen by changing the antimicrobial agent or changing from combination therapy to monotherapy. • In contrast, fixed antibiotic therapy refers to maintaining a broad-spectrum antibiotic regimen until therapy is completed.
  • 45. Should Discontinuation of Antibiotic Therapy Be Based Upon PCT Levels Plus Clinical Criteria or Clinical Criteria Alone in Patients With HAP/VAP? • Using PCT levels plus clinical criteria to guide the discontinuation of antibiotic therapy, rather than clinical criteria alone (weak recommendation, low-quality evidence). • Remarks: It is not known if the benefits of using PCT levels to determine whether or not to discontinue antibiotic therapy exist in settings where standard antimicrobial therapy for VAP is already 7 days or less.
  • 46. Should Discontinuation of Antibiotic Therapy Be Based Upon the CPIS Plus Clinical Criteria or Clinical Criteria Alone in Patients With Suspected HAP/VAP? Not using the CPIS to guide the discontinuation of antibiotic therapy (weak recommendation, low-quality evidence).
  • 47. • Do the difficult things while they are easy and do the great things while they are small. A journey of a thousand miles must begin with a single step. -Lao Tzu. “If you are irritated by every rub, how will your mirror be polished?” ― Rumi

Hinweis der Redaktion

  1. Clinical Pulmonary Infection Score Calculation