Lila BOUADMA (Paris)
Déclaration de liens d'intérêt
The alphabet soup of pneumonia: CAP, HAP, HCAP, NHAP, and VAP. Anand N, Kollef MH.
2009
HCAP
Pneumonia occurring ≤ 48 hours of hospital admission in patients with ≥ 1 of the following risk factors for MDR bacteria as cause of infection: —Hospitalization for ≥ 2 days in an acute-care facility within 90 days of infection —Residence in a nursing home or long-term care facility —Antibiotic therapy, chemotherapy, or wound care within 30 days of current infection —Hemodialysis treatment at a hospital or clinic —Home infusion therapy or home wound care —Family member with infection due to MDR bacteria
HAP
Pneumonia occurring ≥ 48 hours after hospital admission • Risk factors for MDR bacteria causing HAP —Antibiotic therapy within 90 days of infection —Current hospitalization of ≥ 5 days —High frequency of antibiotic resistance in community or specific hospital unit —Immunosuppressive disease or therapy —Presence of HCAP risk factors for MDR
VAP Pneumonia occurring > 48 hours after endotracheal intubation • Risk factors for MDR bacteria causing VAP —Presence of HCAP or HAP risk factors for MDR
Frequency of Occurrence of Bacterial Pathogens Associated With CAP, HCAP, HAP, and VAP (n = 4,543)
Bacterial Pathogens CAP (n =2,221)
HCAP (n = 988)
HAP (n = 835)
VAP (n = 499)
Gram-positive pathogens, % S aureus S aureus (all) 25.5 46.7 47.1 42.5 MSSA (all) 17.2 21.1 26.2 28.5 MSSA only 12.0 14.3 19.3 19.0 MRSA (all) 8.9 26.5 22.9 14.6 MRSA only 6.2 18.3 16.8 11.8 All MRSA as percentage of all SA 34.8 56.8 48.6 34.4 Streptococcus nongroup 13.4 7.8 13.9 7.0 S pneumoniae 16.6 5.5 3.1 5.8 Other Gram positive 7.1 7.7 8.1 8.6 Gram-negative pathogens, % Pseudomonas sp 17.1 25.3 18.4 21.2 Haemophilus sp 16.6 5.8 5.6 12.2 Klebsiella sp 9.5 7.6 7.1 8.4 Escherichia sp 4.8 5.2 4.7 6.4 Enterobacter sp 2.9 3.5 4.3 5.6 Acinetobacter sp 1.6 2.6 2.0 3.0 Other Gram negative 4.1 9.5 3.7 6.2
Epidemiology and Outcomes of Health-care–associated Pneumonia : Results From a Large US Database of Culture-Positive Pneumonia Marin H. Kollef, MD, FCCP, Andrew Shorr, MD, MPH, FCCP, Ying P. Tabak, PhD, Vikas Gupta, harmD, BCPS, Larry Z. Liu, MD, PhD, and R. S. Johannes, MD, MS
2005
Epidemiology and Outcomes of Health-care–associated Pneumonia : Results From a Large US Database of Culture-Positive Pneumonia Marin H. Kollef, MD, FCCP, Andrew Shorr, MD, MPH, FCCP, Ying P. Tabak, PhD, Vikas Gupta, harmD, BCPS, Larry Z. Liu, MD, PhD, and R. S. Johannes, MD, MS
2005
Colimycine, aérosols....
Colimycine, aérosols....
Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock
Kumar, CCM, 2006
Clinical Importance of Delays in the initiation of Appropriate Antibiotic Treatment for Ventilator-Associated Pneumonia Iregui M, Ward S, Sherman G, Fraser VJ, Kollef MH. 2002
78% delay in writing antibiotic orders
Clinical Importance of Delays in the initiation of Appropriate Antibiotic Treatment for Ventilator-Associated Pneumonia Iregui M, Ward S, Sherman G, Fraser VJ, Kollef MH. 2002
Independent Predictors of Hospital Mortality using logistic Regression
Variables Adjusted Odds Ratio
IDAAT 7.68 4.50-13.09 <O.001
Apache II score (1-point increments) 1.13 1.09-1.18 0.001
HAP, VAP or HCAP Suspected
Obtain Lower Respiratory Tract (LRT) Sample for Culture (Quantitative or Semi-quantitative) & Microscopy
Clinical Improvement at 48 -72 Hours
De-escalate Antibiotics, if Possible.
Search for Other Pathogens,
Sites of Infection
Days 2 & 3: Check Cultures & Assess Clinical Response: (Temperature, WBC, Chest X-ray, Oxygenation, Purulent Sputum,
Hemodynamic Changes & Organ Function)
YESYESNONO
Unless There Is Both A Low Clinical Suspicion for Pneumonia & Negative Microscopy of LRT Sample, Begin Empiric Antimicrobial Therapy Using
Algorithm in Figure 2 & Local Microbiologic Data
Cultures -
Pathogens, Complications,Other Diagnoses or Other
Sites of Infection
Cultures +Cultures +Cultures -
Colimycine, aérosols....
Bactéries associées à une antibiothérapie initiale inadaptée
Pseudomonas
Acinetobacter
SDMR
VM > 7 j AB+
n = 158
BGN-NF *(%) 0 23,8 9,3 32,9 Enterobacteriaceae (%) 18,5 19 21,8 10,8 Haemophilus sp (%) 18,6 9,5 3,1 2,5 MR S. auresus (%) 0 4,8 3,1 19,6 MS S. aureus (%) 13,9 0 21,9 3,8 Streptococci (%) 23,2 23,8 28,1 11,4 Divers (%) 25,8 19,1 12,7 19
Influence de la durée de séjour et des AB
*  P.  aeruginosa,  A.  baumanii…  
ATS/IDSA Joined Guidelines-2005 Empiric ANTIBIOTICS for HAP - 2005
HAP, HCAP or VAP suspected (All disease severity)
Late Onset or Risk factors for Antibiotic-resistant (MDR) Bacteria
No Yes
Broad Spectrum Antibiotic Therapy For MDR Pathogens
Quelques règles pour bien choisir l’antibiothérapie initiale chez les patients avec un risque de BMR ?
Associer 2 antibiotiques
Tenir compte des résultats microbiologiques antérieurs
Tenir compte de l’épidémiologie locale
Quelques règles pour bien choisir l’antibiothérapie initiale chez les patients avec un risque de BMR ?
Associer 2 antibiotiques
Tenir compte des résultats microbiologiques antérieurs
Tenir compte de l’épidémiologie locale
2010
Original Article Early combination antibiotic therapy yields improved survival compared with monotherapy in septic shock: a propensity-matched analysis. Kumar A, Zarychanski R, Light B, Parrillo J, Maki D, Simon D, Laporta D, Lapinsky S, Ellis P, Mirzanejad Y, Martinka G, Keenan S, Wood G, Arabi Y, Feinstein D, Kumar A, Dodek P, Kravetsky L, Doucette S; Cooperative Antimicrobial Therapy of Septic Shock (CATSS) Database Research Group.
Risk factors for death
Empiric combination antibiotic therapy is associated with improved outcome against sepsis due to Gram-negative bacteria: a retrospective analysis
Micek, AAC, 2010
Non-ESBL E. Coli 242/248 (98) 2,454/2,489 (99) 0.6 (0.2-1.7) 0.3
ESBL E. coli 21/28 (75%) 62/122 (51) 2.9 (1.1-8.2) 0.02
Non-ESBL K. pneumoniae .62/63 (98) 393/420 (94) 4 (0.7-177) 0.2
ESBL K. pneumoniae 18/20 (90) 38/63 (60) 2 (1.2-4.2) 0.01
P. mirabilis 10/10 (100) 116/118 (98) 1
Salmonella spp. 15/15 (100) 108/109 (99) 1
AmpC organisms 78/82 (95) 258/326 (79) 5.1 (1.8-2.0) 0.001
P. aeruginosa 133/143 (93) 201/319 (63) 7.8 (3.8-1.6) <0.001
Other NF-GNB 24/51 (47) 53/105 (51) 0.9 (0.4-1.8) 0.7
Miscellaneous 18/18 (100) 105/114 (92) 0.4
Influence of empiric therapy with a beta-lactam alone or combined with an aminoglycoside on prognosis of bacteremia due to gram-negative microorganisms.   Mar.nez  JA,  Cobos-­Trigueros  N,  Soriano  A,  Almela  M,  Ortega  M,  Marco   F,  Pitart  C,  Sterzik  H,  Lopez  J,  Mensa  J.  
2010
86
80
55
19
82
83
60
34
Co-trimoxazole
Ofloxacine
Gentamicine
Amikacine
BICHAT - CLAUDE BERNARD 2010
HR IC 95% P
Effectiveness of Combination Antimicrobial Therapy for Pseudomonas aeruginosa Bacteremia Eric Chamot, Emmanuelle Boffi El Amari, Peter Rohner, and Christian Van Delden 2003
Mortalité à J90: Antibiothérapie définitive sur antibiogramme
HR IC 95% P
Effectiveness of Combination Antimicrobial Therapy for Pseudomonas aeruginosa Bacteremia Eric Chamot, Emmanuelle Boffi El Amari, Peter Rohner, and Christian Van Delden 2003
Quelques règles pour bien choisir l’antibiothérapie initiale chez les patients avec un risque de BMR ?
Associer 2 antibiotiques
Tenir compte des résultats microbiologiques antérieurs
Tenir compte de l’épidémiologie locale
ATB inappropriée:      45,5% 21,2% <0,001
Impact of previous antibiotic therapy on outcome of Gram- negative severe sepsis Johnson, Michael T. PharmD; Reichley, Richard PharmD; Hoppe-Bauer, Joan BA, BS, MT; Dunne, W. Michael PhD; Micek, Scott PharmD; Kollef, Marin MD
2011
Feature Articles
Quelques règles pour bien choisir l’antibiothérapie initiale chez les patients avec un risque de BMR ?
Associer 2 antibiotiques
Tenir compte des résultats microbiologiques antérieurs
Tenir compte de l’épidémiologie locale
Données microbiologiques antérieures
Colonisation préalable documentée par les prélèvements à visée clinique: urines, cathéters, poumon, ….. Colonisation préalable documentée par les prélèvements à visée de dépistage (SARM, BLSE….) Prélevements endo-trachéaux de surveillance
Editorial Intensive Care Med (2008) 34:2130–2133
S. Blot P. Depuydt D. Vogelaers
Maximizing rates of empiric appropriate antibiotic therapy with minimized use of broad-spectrum agents: are
surveillance cultures the key? 2008
Overview of studies reporting concordance between surveillance culture results and etiology of VAP
Author Sampling frequency % predicted etiology
Papadomichelakis 2/week 69%
Jung 1/week 72%
Michel 2/week 85%
Depuydt 2/week 69%
Quelques règles pour bien choisir l’antibiothérapie initiale chez les patients avec un risque de BMR ?
Associer 2 antibiotiques
Tenir compte des résultats microbiologiques antérieurs
Tenir compte de l’épidémiologie locale
EVOLUTION  DE  L’INCIDENCE  DES  BMR     POUR  100  ADMISSIONS  
 BICHAT  -­  CLAUDE  BERNARD  1991-­2011  
SARM      Ent  III  C3G-­R*  
 A.  baumannii  
Années
0,10  
 EBLSE  
0,44  
0,68  
1,05  
0,45  
1,9
0,9
0,15
1,2
0,47
0
0,2
0,4
0,6
0,8
1
1,2
1,4
1,6
1,8
2
19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11
In ci
de nc
e/ 10
0 ad
m is
Colimycine, aérosols....
Paramètres PK / PD corrélés avec l’activité in vivo des antibiotiques
Co nc
en tr
CMI
Temps
QI
AUIC
Insufficient β-lactam concentrations in the early phase of severe sepsis and septic shock
  Taccone, Crit Care, 2010
A Systematic Review and Meta-analysis
Falagas, CID, 2013
A randomized trial of 7-day doripenem versus 10-day
imipenem-cilastain for ventilator-associated pneumonia Kollef, Chastre et al, Crit Care, 2012
Doripénème 1g perfusé en 4 heures x 3/j Imipénème 1 g perfusé en 1 heure x 3/J 56,8% vs 45,6% vs (IC 95% [-26,3; 3,8])
Revisiting the loading dose of amikacin for patients with severe sepsis and septic shock
Taccone, Crit care, 2010
> 8 fois CMI de 8 g/mL
Vancomycin dosing in critically ill patients: robust methods for improved continuous-infusion regimens
Roberts JA, AAC, 2011
Vancomycin dosing in critically ill patients: robust methods for improved continuous-infusion regimens
Roberts JA, AAC, 2011
Major  arIcle  
Linezolid in methicillin-resistant Staphylococcus aureus nosocomial pneumonia: a randomized, controlled study. Wunderink  RG,  Niederman  MS,  Kollef  MH,  Shorr  AF,  Kunkel  MJ,  Baruch  A,   McGee  WT,  Reisman  A,  Chastre  J.  
ZEPHyR: une belle étude mais…
- Réponse clinique non disponible pour 73 pts (43 LNZ) dans l’analyse en PP
- Des déséquilibres favorisant le LNZ
- Mortalité en ITTm: LNZ: 28,1%, VANCO: 26,3%
- Pas d’informations sur durées de ventilation mécanique et de séjour en réanimation
- Concentrations sériques de vancomycine
Comment les traiter? PLAN
Quand commencer l’antibiothérapie?
Comment choisir l’antibiothérapie?
Les modalités d’administration
La ré-évaluation à J2-J3
Colimycine, aérosols....
Colimycine, aérosols....
-5
0
5
10
15
20
25
13.1±7.4 8.7±5.2
n
Comparison of 8 vs 15 days of antibiotic therapy for ventilator- associated pneumonia in adults: a randomized trial Chastre J, Wolff M, Fagon JY, Chevret S, Thomas F, Wermert D, Clementi E, Gonzalez J, Jusserand D, Asfar P, Perrin D, Fieux F, Aubas S; PneumA Trial Group
Réduction empirique de la durée du traitement : essai Pneuma
2003
0
5
10
15
20
25
30
35
40
45
50
Superinfection Relapse
Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial Chastre J, Wolff M, Fagon JY, Chevret S, Thomas F, Wermert D, Clementi E, Gonzalez J, Jusserand D, Asfar P, Perrin D, Fieux F, Aubas S; PneumA Trial Group
2003
Antibiotic discontinuation if any of the followings: – Noninfectious etiology for the
infiltrate was demonstrated. – Signs and symptoms suggesting
active infection had all resolved:
– Θ <38.3°C, – Leukocyes <10,000, – Improvement or lack of
progression on chest x-ray, – PaO2/FIO2 >250).
Pts treated for VAP (n=311)
Randomization (n=302)
Outcome missing (n=4)
Completed trial (n=150)
Completed trial (n=140)
Outcome missing (n=8)
A randomized trial of an antibiotic discontinuation policy for clinically suspected ventilator-associated pneumonia Micek ST, Ward S, Fraser VJ, Kollef MH. Department of Pharmacy, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, USA.
Utilisation d’un algorithme clinico-biologique  
2004
A randomized trial of an antibiotic discontinuation policy for clinically suspected ventilator-associated pneumonia Micek ST, Ward S, Fraser VJ, Kollef MH. Department of Pharmacy, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, USA. 2004
Utilisation d’un algorithme clinico-biologique  
Outcomes Discontinuation group
Hospital LOS, days 16 ± 18 15 ± 16 0.86
ICU LOS, days 7 ± 6 7 ± 7 0.79
Duration of MV, days 5 ± 6 6 ± 7 0.65
Subsequent infection, % 37.3 32.9 0.42
A randomized trial of an antibiotic discontinuation policy for clinically suspected ventilator-associated pneumonia Micek ST, Ward S, Fraser VJ, Kollef MH. Department of Pharmacy, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, USA. 2004
Utilisation d’un algorithme clinico-biologique  
Procalcitonin for reduced antibiotic exposure in ventilator-associated pneumonia:
ProVAP and PRORATA studies
PRORATA study
Antibiotic duration of treatment for patients included for a VAP episode
Mean ± SD
Control group (N = 66)
CONCLUSIONS
1. Le choix initial de l’antibiothérapie au cours des PAVM reste un exercice
difficile qui doit tenir compte d’un ensemble de paramètres liés ou non au patient.
2. Comme pour toutes les infections, la ré-évaluation à J2-J3 est indispensable.
3. L’administration des antibiotiques doit tenir compte de leur propriétés PK.
4. Une durée de traitement courte est possible.
Comment les prévenir?
State of the Art Ventilator-associated Pneumonia Jean Chastre and Jean-Yves Fagon
INDEPENDENT FACTORS FOR VENTILATOR-ASSOCIATED PNEUMONIA IDENTIFIED BY MULTIVARIATE ANALYSIS IN SELECTED STUDIES
Host factors Intervention factors Other factors
Serum albumin, <2.2 g/dl H2 blockers ± antiacids Season: fall, winter
Age, ≥ 60yr Paralytic agents, continuous intravenous sedation
ARDS > 4 units of blood products
COPD, pulmonary disease Intracranial pressure monitoring
Coma or impaired consciousness MV > 2 d
Burns, trauma Positive end-expiratory pressure
Organ failure Frequent ventilator circuit changes
Severity of illness Reintubation
Gastric colonization and pH Supine head position
Upper respiratory tract colonization Transport out of the ICU
Sinusitis Prior antibiotic or no antibiotic therapy
Les mesures de prévention citées dans les recommandations sont:
•soit non évaluées mais reposant sur des principes généraux de prévention
des infections nosocomiales
•soit évaluées par rapport à un mécanisme physiopathologique supposé
•soit LE PLUS SOUVENT évaluées par rapport à des variations de taux
d’infections RAREMENT sur des critères de jugement robustes
Beaucoup d’études ++++++++++  
Lila Bouadma, Michel Wolff and Jean-Christophe Lucet
Un petit………… listing
3) La trachéotomie précoce
4) La stase gastrique
6) La décontamination oropharyngée
9) La fibroscopie
Cook, D. J. et. al. Ann Intern Med 1998;129:433-440
Hazard rate for ventilator-associated pneumonia during the stay in the intensive care unit
Time in Intensive care Unit, d
H az
ar d
R at
e of
P ne
um on
2003
 
Articles 2008 Efficacy and safety of a paired sedation and ventilator
weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial Timothy  D  Girard,  John  P  Kress,  Barry  D  Fuchs,  Jason  W  W  Thomason,  William  D  Schweickert,  Brenda  T  Pun,  Darren  B   Taichman,  Jan  G  Dunn,  Anne  S  Pohlman,  Paul  A  Kinniry,  James  C  Jackson,  Angelo  E  Canonico,  Richard  W  Light,  Ayumi  K   Shintani,  Jennifer  L  Thompson,  Sharon  M  Gordon,  Jesse  B  Hall,  Robert  S  DiLus,  Gordon  R  Bernard,  E  Wesley  Ely  
CARING FOR THE CRITICALLY ILL PATIENT
Early vs Late Tracheotomy for Prevention Of Pneumonia in Mechanically Ventilated Adult ICU Patients A Randomized Controlled Trial Pier  Paolo  Terragni,  Massimo  Antonelli,  Roberto  Fumagalli,  Chiara  Faggiano,  Maurizio  Berardino,  Franco  Bobbio  Pallavicini,  Antonio  Mile\o,   Salvatore   Mangione,   Angelo   U.   Sinardi,   Mauro   Pastorelli,   Nicole\a   Vivaldi,   Alberto   Pase\o,   Giorgio   Della   Rocca,   Rosario   Urbino,   Claudia   Filippini,  Eva  Pagano,  Andrea  Evangelista,  Gianni  Ciccone,  Luciana  Mascia,  V.  Marco  Ranieri  
2010
2007  
AutomaIc  control  of  tracheal  tube  cuff  pressure  in  venIlated   paIents  in  semirecumbent  posiIon:  a  randomized  trial     Valencia,  Mauricio  MD;  Ferrer,  Miquel  MD;  Farre,  Ramon  PhD;  Navajas,  Daniel  PhD;  Badia,     Joan  Ramon  MD;  Nicolas,  Josep  Maria  MD;  Torres,  Antoni  MD  
ConInuous  Control  of  Tracheal  Cuff  Pressure  and   MicroaspiraIon  of  Gastric  Contents  in  CriIcally    Ill  PaIents   Saad  Nseir1,2,  Farid  Zerimech3,  Clément  Fournier4,  Rémy  Lubret1,  Philippe  Ramon4,   Alain  Durocher1,2  and  Malika  Balduyck3,5  
Intervention Control 0
Review Article
Subglo[c  secreIon  drainage  for  the  prevenIon  of  venIlator-­associated  pneumonia:   a  systemaIc  review  and  meta-­analysis.     Muscedere  J,  Rewa  O,  McKechnie  K,  Jiang  X,  Laporta  D,  Heyland  DK.  
VAP
DMS
Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. Reignier J, Mercier E, Le Gouge A, Boulain T, Desachy A, Bellec F, Clavel M, Frat JP, Plantefeve G, Quenot JP, Lascarrou JB; Clinical Research in Intensive Care and Sepsis (CRICS) Group.
CARING FOR THE CRITICALLY ILL PATIENT
2013
PrevenIon  of  venIlator-­associated  pneumonia  with  oral   anIsepIcs:  a  systemaIc  review  and  meta-­analysis     Sonia  O  Labeau,  Katrien  Van  de  Vyver,  Nele  Brusselaers,  Dirk  Vogelaers,  SQjn  I  Blot  
Articles
PrevenIon  of  venIlator-­associated  pneumonia  with  oral   anIsepIcs:  a  systemaIc  review  and  meta-­analysis     Sonia  O  Labeau,  Katrien  Van  de  Vyver,  Nele  Brusselaers,  Dirk  Vogelaers,  SQjn  I  Blot  
Articles
1904 = SOD 2045 = SDD
SDD = SOD > standard care
27.5% de mortalité dans le groupe standard care et
diminution d’environ 3% de la mortalité dans les 2 autres groupes
Decontamination of the Digestive Tract and Oropharynx in ICU Patients A.M.G.A. de Smet, M.D., J.A.J.W. Kluytmans, M.D., Ph.D., B.S. Cooper, Ph.D., E.M. Mascini, M.D., Ph.D., R.F.J. Benus, M.D., T.S. van der Werf, M.D., Ph.D., J.G. van der Hoeven, M.D., Ph.D., P. Pickkers, M.D., Ph.D., D. Bogaers-Hofman, I.C.P., N.J.M. van der Meer, M.D., Ph.D., A.T. Bernards, M.D., Ph.D., E.J. Kuijper, M.D., Ph.D., J.C.A. Joore, M.D., M.A. Leverstein-van Hall, M.D., Ph.D., A.J.G.H. Bindels, M.D., Ph.D., A.R. Jansz, M.D., R.M.J. Wesselink, M.D., Ph.D., B.M. de Jongh, M.D., Ph.D., P.J.W. Dennesen, M.D., Ph.D., G.J. van Asselt, M.D., Ph.D., L.F. te Velde, M.D., I.H.M.E. Frenay, M.D., Ph.D., K. Kaasjager, M.D., Ph.D., F.H. Bosch, M.D., Ph.D., M. van Iterson, M.D., S.F.T. Thijsen, M.D., Ph.D., G.H. Kluge, M.D., Ph.D., W. Pauw, M.D., J.W. de Vries, M.D., Ph.D., J.A. Kaan, M.D., J.P. Arends, M.D., L.P.H.J. Aarts, M.D., Ph.D., P.D.J. Sturm, M.D., Ph.D., H.I.J. Harinck, M.D., Ph.D., A. Voss, M.D., Ph.D., E.V. Uijtendaal, Pharm.D., H.E.M. Blok, M.Sc., E.S. Thieme Groen, M.D., M.E. Pouw, M.D., C.J. Kalkman, M.D., Ph.D., and M.J.M. Bonten, M.D., Ph.D
Conclusions
Les mesures générales +++++
Les méthodes avec une efficacité sur des critères de jugement robustes:
-La diminution de l’exposition au risque
-L’aspiration sous glottique
-La DOS, la DDS
Major Points and Recommendations for Modifiable Risk Factors General prophylaxis.
1. Effective infection control measures: staff education, compliance with alcohol-based hand disinfection, and isolation to reduce cross-infection with MDR pathogens should be used routinely (Level I). 2. Surveillance of ICU infections, to identify and quantify endemic and new MDR pathogens, and preparation of timely data for infection control and to guide appropriate, antimicrobial therapy in patients with
suspected HAP or other nosocomial infections, are recommended (Level II).
Intubation and mechanical ventilation. 1. Intubation and reintubation should be avoided, if possible, as it increases the risk of VAP (Level I). 2. Noninvasive ventilation should be used whenever possible in selected patients with respiratory failure (Level I). 3. Orotracheal intubation and orogastric tubes are preferred over nasotracheal intubation and nasogastric tubes to prevent nosocomial sinusitis and to reduce the risk of VAP, although direct causality has not been
proved (Level II). 4. Continuous aspiration of subglottic secretions can reduce the risk of early-onset VAP, and should be used, if available (Level I). 5. The endotracheal tube cuff pressure should be maintained at greater than 20 cm H2O to prevent leakage of bacterial pathogens around the cuff into the lower respiratory tract (Level II). 6. Contaminated condensate should be carefully emptied from ventilator circuits and condensate should be prevented from entering either the endotracheal tube or in-line medication nebulizers (Level II). 7. Passive humidifiers or heat–moisture exchangers decrease ventilator circuit colonization, but have not consistently reduced the incidence of VAP, and thus they cannot be regarded as a pneumonia prevention tool
(Level I). 8. Reduced duration of intubation and mechanical ventilation may prevent VAP and can be achieved by protocols to improve the use of sedation and to accelerate weaning (Level II). 9. Maintaining adequate staffing levels in the ICU can reduce length of stay, improve infection control practices, and reduce duration of mechanical ventilation (Level II).
Aspiration, body position, and enteral feeding.
1. Patients should be kept in the semirecumbent position (30–45°) rather than supine to prevent aspiration, especially when receiving enteral feeding (Level I). 2. Enteral nutrition is preferred over parenteral nutrition to reduce the risk of complications related to central intravenous catheters and to prevent reflux villous atrophy of the intestinal mucosa that may increase the
risk of bacterial translocation (Level I).
Modulation of colonization: oral antiseptics and antibiotics. 1. Routine prophylaxis of HAP with oral antibiotics (selective decontamination of the digestive tract or SDD), with or without systemic antibiotics, reduces the incidence of ICU-acquired VAP, has helped contain
outbreaks of MDR bacteria (Level I), but is not recommended for routine use, especially in patients who may be colonized with MDR pathogens (Level II). 2. Prior administration of systemic antibiotics has reduced the risk of nosocomial pneumonia in some patient groups, but if a history of prior administration is present at the time of onset of infection, there should be
increased suspicion of infection with MDR pathogens (Level II). 3. Prophylactic administration of systemic antibiotics for 24 hours at the time of emergent intubation has been demonstrated to prevent ICU-acquired HAP in patients with closed head injury in one study, but its routine
use is not recommended until more data become available (Level I). 4. Modulation of oropharyngeal colonization by the use of oral chlorhexidine has prevented ICU-acquired HAP in selected patient populations such as those undergoing coronary bypass grafting, but its routine use is
not recommended until more data become available (Level I). 5. Use daily interruption or lightening of sedation to avoid constant heavy sedation and try to avoid paralytic agents, both of which can depress cough and thereby increase the risk of HAP (Level II).
Stress bleeding prophylaxis, transfusion, and hyperglycemia.
1. Comparative data from randomized trials suggest a trend toward reduced VAP with sucralfate, but there is a slightly higher rate of clinically significant gastric bleeding, compared with H2 antagonists. If needed, stress bleeding prophylaxis with either H2 antagonists or sucralfate is acceptable (Level I).
2. Transfusion of red blood cell and other allogeneic blood products should follow a restricted transfusion trigger policy; leukocyte-depleted red blood cell transfusions can help to reduce HAP in selected patient populations (Level I).
3. Intensive insulin therapy is recommended to maintain serum glucose levels between 80 and 110 mg/dl in ICU patients to reduce nosocomial blood stream infections, duration of mechanical ventilation, ICU stay, morbidity, and mortality (Level I).
Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.
Am J Respir Crit Care Med, 2005. 171(4): p. 388-416.
RECOMMANDATIONS
BUNDLES
OUTILS
ALGORITHMES
Traduction de « bundle » = faisceau fasces lictoriae (latin) fasci, fasco (italien)
Bundles of the lictors The fasces lictoriae
C’est une méthode structurée pour améliorer le processus de soin
(et donc le pronostic des patients).
Il est composé d’un petit ensemble simple et cohérent de plusieurs pratiques,
généralement 3 à 5, bien définies, fondées sur des preuves scientifiques solides
et qui mis en œuvre correctement (95% d’adhérence), se traduit par un meilleur
résultat sur le pronostic que lorsque chaque mesure est utilisée seule.
DEFINITION « Bundle » selon l’Institute for Healthcare Improvement (IHI)
DEFINITION « Bundle » selon l’Institute for Healthcare Improvement (IHI)
3 à 5 mesures de prévention Mise en œuvre
Adhérence aux
mesures (95%)
1) la prophylaxie de l’ulcère de stress,
2) la prophylaxie des thromboses veineuses profondes, 3) l'élévation de la tête du lit, 4) l’arrêt des sédations et l’évaluation des possibilités de sevrage 5) soins de bouche à la chlorhexidine
A European care bundle for prevention of ventilator-associated pneumonia
Rello, ICM, 2010 Criterion Mean weighting score Ease of implementation within a care bundle package How easy it will be to implement the element of the care bundle? 18
Clinical effectiveness against VAP and the likely benefit Is there evidence that the intervention is clinically effective in its impact upon VAP? How big a benefit does the intervention produce?
16
Strength of clinical evidence concerning the intervention How good is the evidence that demonstrates the benefit of the intervention? Is all the evidence of the same standard? Are the study results relevant across the range of health systems?
15
Consistency of findings from different studies Are the findings of these studies consistent? Do the studies demonstrating benefit come from a range of health systems?
9
Generalisability to different health care systems and settings Is the recommendation acceptable across different health care systems? 9
Volume of clinical evidence supporting the intervention How many studies are available to show that benefit exists from the recommendation? Do the studies demonstrating benefit come from a range of health systems?
8
Cost effectiveness of the intervention Is the intervention cost effective? How cost effective is the intervention across the different health care systems?
7
Coverage in all VAP patients Is the benefit uniform across the complete VAP group of patients? 5
Impact on the health care system as a whole Think about the impact (positive or negative) on other services, e.g. will this intervention increase/decrease work load for other services (can this other part of the service deliver?), e.g. laboratories/imaging
3
1
ORIGINAL Jordi Rello Hartmut Lode, Giuseppe Cornaglia Robert Masterton The VAP Care Bundle Contributors
Intensive care med (2010) 36: 1841-1845
A European care bundle for prevention of ventilator-associated pneumonia
492
527
543
552
562
573
573
614
614
623
674
682
705
716
747
583
Semi recumbent patient positioning
Use sucralfate where stress ulcer prophylaxis required
Enteral feeding
Avoid stress ulcer prophylaxis
Non invasive ventilation preferred
Sedation vacation and weaning protocol
Oral care with chlorexadine
Strict hand hygiene using alcohol
Appropriately educated and trained staff
Ranking of VAP prevention interventions.
ORIGINAL Jordi Rello Hartmut Lode, Giuseppe Cornaglia Robert Masterton The VAP Care Bundle Contributors
Intensive care med (2010) 36: 1841-1845
A European care bundle for prevention of ventilator-associated pneumonia
EDITORIAL COMMENTARY
Ventilator-associated Pneumonia: Is zero Possible? Michael Klompas 2010
Study, year Design VAP rate before VAP rate after VAP reduction, % P
Zack et al Before-after 12.6 5.7 58 <.001 Crunden et al Before-after NR NR NR NR Resar et al Before-after 6.6 2.7 59 <.001 Berriel-Cass et al Before-after 8.2 3.3 60 .02 Burger and Resar Before-after 6.0 0.7 88 NR Cocanour et al Before-after 22.3 10.7 52 <.05 Apisarnthanarak et al Before-after 20.6 8.5 59 .001 Yougquist et al Before-after 6.1 0 100 NR Yougquist et al Before-after 2.7 1.7 37 NR Blamoun et al Before-after 14.1 0 100 .006 Bloos et al Before-after 37.6 45.9 +22 NR Hawe et al Before-after 19.2 7.5 61 NR Hutchins et al Before-after 12.6 1.3 90 NR Marra et al Before-after 16.4 10.4 37 .05 Zaydfudim et al Before-after 15.2 9.3 39 .01 Bird et al Before-after 10.2 3.4 67 .004 Bouadma et al Before-after 22.6 13.1 43 <.001 Morris et al Before-after 32 12 63 <.001
DEFINITION « Bundle » selon l’Institute for Healthcare Improvement (IHI)
3 à 5 mesures de prévention Mise en œuvre
Adhérence aux
mesures (95%)
Ils ont plusieurs avantages:
Ø ils permettent de contourner les contraintes du "case mix”,
Ø l’objectif est clair = observance de 100% (95%),
Ø la surveillance est en général facile,
Ø ils sont plus fréquents que les infections si bien qu’il est facile
de détecter rapidement une déviation par rapport aux bonnes
pratiques et de la corriger .