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Transcript

Erin Martinko Duke University N664

treatment of Ventilator Associated Pneumonia (VAP)

Objectives

Monitor and Evaluate Treatment Response

Understand Source Control

Recognize the Role of Supportive Care

Implement Appropriate Antibiotic Stewardship

Understand the Principles of Empiric Antibiotic Therapy

Risk factors include age, underlying illness, immunosuppression, prolonged mechanical ventilation, and improper ventilator circuit changes.

Biofilm formation on the endotracheal tube

Impaired Host Defernses

Aspitation into the lower respiratory tract

Colonization of the oropharynx

  • Significantly increases morbidity, mortality, length of hospital stay, and health care costs.

Introduction

VAP is a type of lung infection that occurs in patients on mechanical ventilation for at least 48 hours.

Empiric Antibiotic Therapy

Consider patient factors such as prior antibiotic use, allergy history, and risk of multidrug-resistant organisms.

Use local antibiogram data to guide your selection

Antibiotics should cover common pathogens--> gram--negative bacilli and staph. aureus

Iniatiate empric antibiotics promptly based on clinical suspiction

EMPIRIC ANTIBIOTIC THERAPY

QUESTION 1
  • Avoid unnessary use of broad-spectrum antibiotics.
  • Follow local guidelines and protocols for antibiotic use.
  • Typically, 7-8 days of antibiotic therapy is sufficient for most patients with VAP.
  • Longer durations may be needed for patients with complicated infections or slow clinical response.
  • Adjust antibiotics based on culture and sensitivity results to target specific pathogens.
  • De-escalation helps reduce the risk of antibiotic resistance and adverse effects.

Antibiotic Stewardship

Strategies to prevent antibiotic resistance

Duration of therapy

De-escalation based on culture results

ANTIBIOTIC STEWARDSHIP

Question 2
  • Provide adequate nutrition to support immune function and recovery.
  • Consider enteral feeding as the preferred method of nutritional support.
  • Manage fluid balance carefully to avoid fluid overload and pulmonary edema.
  • Use diuretics if necessary to maintain euvolemia
  • Ensure patients receive appropriate oxygen therapy to maintain adequate oxygen saturation levels.
  • Adjust ventilator settings to optimize oxygen delivery and minimize lung injury.

Nutritional Support

Fluid Management

Adequate Oxygenation

Supportive Care

SUPPORTIVE CARE

Question 3
  • Replace the ET tube if there is suspicion of biofilm formation or persistent infection.
  • Removal may be necessary if the patient is ready for extubation.
  • Ensure proper placement and securement of endotracheal tubes.
  • Consider subglottic suctioning to remove secretions about the cuff.
  • Effective source control is crucial for resolving infection and preventing recurrence.

When to Consider Removing/Replacing the ET Tube

Management of Endotracheal Tubes

Importance of Source Control

Source Control

SOURCE CONTROL

QUESTION 4
  • Consider patient's clinical improvement, labortory findings, and radiographic changes.
  • Adjust treatment based on overall clinical assessment.
  • Monitor vital signs, including temperature and oxygen saturation.
  • Check white blood cell count and assess for clinical signs of infection resolution.
  • Follow up with chest x-ray to evaluate radiologic improvement
  • Reassess respiratory cultures to confirm clearance of the pathogen.
  • Adjust antibiotics if there is persistence of infection.

Monitoring and Followup

Criteria for Assessing Response

Microbiological Parameters: Culture Results

Clinical Parameters

Fever, WBC count, Oxygenation, Radiologic Improvement

MONITORING AND FOLLOW-UP

QUESTION %
  • American Thoracic Society & Infectious Diseases Society of America. (2005). Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. American Journal of Respiratory and Critical Care Medicine, 171(4), 388–416. https://doi.org/10.1164/rccm.200405-644st
  • Chastre, J., & Fagon, J.-Y. (2002a). Ventilator-associated pneumonia. American Journal of Respiratory and Critical Care Medicine, 165(7), 867–903. https://doi.org/10.1164/ajrccm.165.7.2105078
  • Kalil, A. C., Metersky, M. L., Klompas, M., Muscedere, J., Sweeney, D. A., Palmer, L. B., Napolitano, L. M., O'Grady, N. P., Bartlett, J. G., Carratalà, J., El Solh, A. A., Ewig, S., Fey, P. D., File, T. M., Restrepo, M. I., Roberts, J. A., Waterer, G. W., Cruse, P., Knight, S. L., & Brozek, J. L. (2016a). Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the infectious diseases society of america and the american thoracic society. Clinical Infectious Diseases, 63(5), e61–e111. https://doi.org/10.1093/cid/ciw353
  • Kollef, M. H., & Micek, S. T. (2005). Strategies to prevent antimicrobial resistance in the intensive care unit. Critical Care Medicine, 33(8), 1845–1853. https://doi.org/10.1097/01.ccm.0000171849.04952.79
  • Mumtaz, H., Saqib, M., Khan, W., Ismail, S. M., Sohail, H., Muneeb, M., & Sheikh, S. S. (2023). Ventilator associated pneumonia in intensive care unit patients: A systematic review. Annals of Medicine & Surgery, 85(6), 2932–2939. https://doi.org/10.1097/ms9.0000000000000836
  • Tamma, P. D., Avdic, E., Li, D. X., Dzintars, K., & Cosgrove, S. E. (2017). Association of adverse events with antibiotic use in hospitalized patients. JAMA Internal Medicine, 177(9), 1308. https://doi.org/10.1001/jamainternmed.2017.1938

References

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