TURKISH THORACIC SOCIETY

HOSPITAL ACQUIRED PNOMONIAE CONSENSUS STATEMENT,2008

AUTHORS

Oğuz KILINÇ(Chair) Turhan ECE (Secretary) Dilek ARMAN Nahit ÇAKAR Nedim ÇAKIR

Ali GÜNERLİ

Eyüp Sabri UÇAN

Sercan ULUSOY

Haluk VAHAPOĞLU

COMMITTEE MEMBERS

Halis AKALIN Füsun ALATAŞ Feza BACAKOĞLU Kadir BİBEROĞLU Semra ÇALANGU Haluk C. ÇALIŞIR Hülya ELLİDOKUZ

Zeynep GÜLAY Selma KARABEY Volkan KORTEN Emine OSMA

Metin ÖZKAN

Halit ÖZSÜT Tülay YARKIN

NEW DEFINITION

Healthcare-associated pneumoniae (HCAP)

Nosocomial tracheobronchitis Ventilator-associated

tracheobronchitis

NEW DEFINITION

Healthcare- associated pneumoniae; Hospitalization for 2 d or more in the preceding

90 d Residence in a nursing home or extended care

facility Home infusion therapy (including antibiotics) Chronic dialysis within 30 d Home wound care Family member with multidrug-resistant

pathogen

NEW DEFINITION

Nosocomial tracheobronchitis*

When fever, leukocytosis, purulent sputum, and a positive culture of a sputum or tracheal aspirate are present without a new lung infiltrate,

*Occurs 48 hours or more afteradmission, which was not incubating at the time of admission

NEW DEFINITION

Ventilator- associated tracheobronchitis * When fever, leukocytosis,

purulent sputum, and a positive culture of a sputum or tracheal aspirate are present without a new lung infiltrate

*Occurs 48 hours or more aftermechanically ventilation, which was not incubating at the time of MV

PATHOGENESIS

Aspiration of oropharyngeal pathogens,

Inhalation Hematogenous spread

ETIOLOGY

Early- onset (3.-4. day) Streptococcus pneumoniae, Haemophilus influenzae Methicilline sensitive Staphylococcus

aureus’tur Late- onset (after 5 day)

P. aeruginosa Acinetobacter spp. Enterobacter spp. Klebsiella spp. MRSA

RISK FACTORS (increased mortality)

Inappropriate treatment Previous antibiotic usage Duration of hospital stay and ICU Prolonged MV Multilober and/or bilateral pulmoner infiltration Severity of underlying diseases APACHE II, SAPS Severe sepsis/septic shock, multiorgan disfunction

syndrom (MODS) Elderly age (>65) PaO2/FiO2< 240

RISK FACTORS (increased mortality)

MDR pathogens P. aeruginosa Acinetobacter spp* Stenotrophomonas maltophilia S. aureus(methicilline resistant) MRSA

DIAGNOSIS- Clinical

New or progressive infiltrate on chest x-ray and

> 38 0C fever Leukocytosis or Leukopenia Purulen sputum Decline in oxygenation

DIAGNOSIS-CPIS Clinical Pulmonary Infection Score (CPIS)

DeğişkenlerScore 0 Score1 Score 2

Fever 0C ≥36.1, ≤ 38.4 ≥ 38.5, ≤ 38.9 ≥ 39, ≤ 36

WBC count μ/L ≥4000, ≤ 11.000 <4000, >11.000

Secretions Absent Present,nonpurulent Present purulent

PaO2/ FiO2 > 240 or ARDS <240 and without ARDS

Chest x-ray İnfiltration absent Diffuse or patchy infiltrate

Localized infiltrate

Microbiology No or light growth Moderate or heavy growth*1 point for same organism on Gram stain

CPIS > 6 is often regarded as consistent with a diagnosis of pneumonia especially in VAP

DIAGNOSIS- first step tests

Sputum,pleural fluid, tracheal secretion culture

Two step, blood culture

DIAGNOSIS- second step tests

BAL PSB TTA FNAB Open lung biopsy

CLASSIFICATION AND TREATMENT

GROUP 1 Early- onset

GROUP 2 Late- onset (risk factors for mortality

and MDR pathogen (-) GROUP 3

Early-onset /Late onset (risk factors for mortality and for MDR pathogen (+)

Pathogens

A-MDR pathogen riskB-Risk factors for mortality C- HCAP

Group 1(Early onset)A B C absent

Group 2(Late onset)

A B C absent

Grup 3Early-onset or late

onset( A and/or B and/or C

present)

Core pathogens:S. pneumoniaeH. influenzaeM.catarrhalis

A.S.aureus ( methicilline sensitive)

Enterobacter spp.K. pneumoniaeS. marcescensE. coliOther Gram negative rods +S. aureus (methicilline sensitive)

Core pathogens

P.aeruginosa,Acinetobacter spp. S.aureus (methicilline resistant)K.pneumoniaeS. maltophilia +Group 2 pathogens

CLASSIFICATION AND TREATMENT

Group 1 (Monotherapy)

Ampisilin-Sulbaktam/ Co-amoksilavor

Cefuroxime/Ceftriaxoneor

Levofloxacin/ Moksifloxacin *

Group 2 (Monotherapy)

Sulbaktam- ampicilline

or

Ceftriaxone/Cefotaxime

or

Ofloxacine

or

Levofloxacin/Moksifloxacin

or

Piperacillin-tazobaktam

Group 3 (Monotherapy/ Combination)Piperacillin- tazobaktam

orCeftazidim, Cefepime, Cefoperazon-Sulbaktam

orImipenem, Meropenem

Amicasin or Ciprofloxacin

orColistin**

Linezolid***, Teikoplanin, Vankomycine

*Combination therapy for MDR pathogens. After 72 hrs If CPIS ≤6 swicth monotherapy ** Especially in MDR pathogens***Don’t use Linezolid empirically

DURATION OF TREATMENT

If patients receive an initially appropriate antibiotic regimen, efforts should be made to shorten the duration of therapy from the traditional 14 to 21 days to periods as short as 7 days, provided that the etiologic pathogen is not P. aeruginosa, and that the patient has a good clinical response (CPIS ≤6) with resolution of clinical features of infection

RESPONSE TO THERAPY

Resolution of fever Clinical improvement WBC count PaO2/ FiO2 improvement CPIS ≤ 6 CRP value decrease %40 at 4. day

Prevention

Hospital Infection Association Turkish Thoracic Society

“Guidelines for Prevention of Hospital Acquired pneumonia”