Objectives: 1.To review the latest updates in the Canadian VAP Guidelines 2.To highlight the changes and why these changes are important Read more and watch the recorded webinar: http://bit.ly/1sRCowQ

1. LATEST UPDATES TO THE CANADIAN VAP GUIDELINES
Tuesday, September 30 2014
Mardi 30 Septembre 2014

2. 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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6. Dr. John Muscedere
Latest Updates to the Canadian
VAP Guidelines

7. Canadian Clinical Practice Guidelines for Ventilator Associated Pneumonia (VAP)
Dr. John Muscedere
Queen’s University

8. 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

9. Epidemiology of VAP

10. 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)

11. Hospital Location & Relative Frequency of HAP & VAP
HAP
ICU HAP
Non-ICU
HAP
VAP
Non-ICU HAP
ICU HAP
VAP
ICU HAP
HAP
ICU

12. 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

13. 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

14. 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

15. 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

16. Pathogenesis of HAP/VAP

17. Pathogenesis of VAP

18. Causative Pathogens

19. 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)

20. 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)

21. 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

22. 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

23. Invasive
ETT Aspirate
Obtaining Microbiological Sample for Diagnosis of VAP
Bronchoscopy
Non-Invasive
Quantitative Cultures
Non- Quantitative Cultures

24. Mortality of BAL vs ETA
Meta-Analysis of All trials comparing ETA with BAL

25. VAT

26. 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

27. 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)

28. 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)

29. VAP Guideline Recommendations
•
Prevention
•
Diagnosis
•
Treatment

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

31. •
Use Oral Route for intubation
May not apply to pts with:
•Maxillofacial trauma/surgery
•ENT surgery
•Difficult intubation
VAP Guideline Recommendations: Prevention

32. Sub-glottic Secretion Drainage
VAP Guideline Recommendations: Prevention

33. Sub-glottic Secretion Drainage
Muscedere et al, CCM 2011

34. •
Subglottic Secretion Drainage
•
Requirement for prolonged mechanical ventilation
May not apply to pts with:
•Nasally intubation
•Tracheostomy tube
•Difficult endotracheal intubation
VAP Guideline Recommendations: Prevention

35. •
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 Guideline Recommendations: Prevention

36. 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

37. •
Chlorhexidine Oral Antiseptic
May not apply to pts with:
•Chlorhexidine Allergy
•Lack of access to patient’s oral cavity
VAP Guideline Recommendations: Prevention

38. CHX decontamination compared with no prophylaxis on risk of VAP

39. VAP Guidelines: Diagnosis

40. •
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

41. •
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

42. 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

43. VAP Guidelines: Treatment

44. 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

45. 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

46. •
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

47. •
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
VAP Guideline Recommendations: Treatment

48. VAP Guideline Recommendations: Treatment
Monotherapy vs. Combination Therapy: Mortality

49. •
Choice of antibiotics for empiric treatment of VAP
•
Based on local ICU resistance patterns and patient factors
May not apply to pts with: none
VAP Guideline Recommendations: Treatment

51. •
Discontinuation of empiric antibiotics for VAP
•
If noninfectious etiology of infiltrates is found
OR
•
If signs and symptoms of active infection have resolved
May not apply to pts with: none
VAP Guideline Recommendations: Treatment

52. •
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)
VAP Guideline Recommendations: Treatment

53. MRSA VAP Pneumonia
In the three studies
•
Mortality at different time points reported
•
No effect on mortality was reported
Clinical cure rate

54. •
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
VAP Guideline Recommendations: Treatment

55. 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

56. Thank You
Questions?

57. QUESTIONS? RAISE YOUR HAND / LEVEZ LA MAIN OR/OU CHAT TO “ALL PARTICIPANTS”

58. “Taking the Pulse” Poll
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59. Instructions to download certificate
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60. 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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61. Reminders Rappels

Call is recorded

Slides and links to recordings will be available on Safer Healthcare Now! Communities of Practice

Additional resources are available on the SHN Website and Communities of Practice

L'appel est enregistré

Les diapositives et liens vers les enregistrements seront disponibles sur Des soins de santé plus sécuritaires maintenant! Communautés de pratique

Des ressources supplémentaires sont disponibles sur le site Web SSPSM et Communautés de Pratique
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62. THANK YOU MERCI

63. This National Call is hosted by:
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