LATEST UPDATES TO THE CANADIAN VAP GUIDELINES
Tuesday, September 30 2014
Mardi 30 Septembre 2014
Your Hosts & Presenters Vos hôtes et présentateurs
Bruce Harries, Collaborative Director
Denny Laporta, MD, MSc, FRCPC; ...
Interacting in WebEx: Today’s Tools Interagir dans Webex : outils à utiliser
3
Be prepared to use:
- Pointer
- Raise h...
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Who’s Online? Qui est en ligne?
POINTER
08/05/2014
What professions are represented? Quelles professions sont représentées?
Nurse
MD
Educator / Quality Improvement Profes...
Dr. John Muscedere
Latest Updates to the Canadian
VAP Guidelines
Canadian Clinical Practice Guidelines for Ventilator Associated Pneumonia (VAP)
Dr. John Muscedere
Queen’s University
Learning Objectives
1.To understand the epidemiology of VAP.
2.To review the principles of diagnosis for VAP
3.To revie...
Epidemiology of VAP
Hospital-Acquired Pneumonia (HAP): Definitions

Hospital Acquired Pneumonia:

Arises 48 hours or more after hospital...
Hospital Location & Relative Frequency of HAP & VAP
HAP
ICU HAP
Non-ICU
HAP
VAP
Non-ICU HAP
ICU HAP
VAP
ICU HAP
...
Why the focus on VAP?

Increased Mortality

Depends on population

Adequacy and timeliness of antibiotic treatmen...
VAP: Impact

Increases ICU Stay, Increases duration of Mechanical Ventilation and Increases duration of Hospital Stay
...
VAP: Canadian Healthcare Costs
1Based on attributable mortality of 5.8%
2Ontario cost cost methodology
Muscedere et al,...
Incidence
•
Depends on how hard one looks
•
Surveillance underestimates true incidence
•
Reported rates vary:
•
US...
Pathogenesis of HAP/VAP
Pathogenesis of VAP
Causative Pathogens
Classification of HAP & VAP: Risk Stratification
Time from Hospitalization (days)
Time from Intubation (days)
Early-ons...
Pathogens to Consider When Treating HAP/VAP
Early HAP/VAP
Late HAP/VAP
Timing
Within five days of admission or mechani...
Diagnosis of VAP
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No reference standard for VAP
•
Clinical features are non-specific and can be found in many other d...
Diagnosis of VAP
Clinical
+
Microbiology
•
Purulent secretions
•
Increasing oxygen requirements
•
Core temp > 38....
Invasive
ETT Aspirate
Obtaining Microbiological Sample for Diagnosis of VAP
Bronchoscopy
Non-Invasive
Quantitative Cu...
Mortality of BAL vs ETA
Meta-Analysis of All trials comparing ETA with BAL
VAT
Possible pneumonia
Probable
pneumonia
VAC ventilator-associated condition
New and sustained respiratory deterioration ...
Definition:
≥2 days of stable or decreasing daily minimum PEEP or FiO2
followed by
Rise in daily minimum PEEP ≥3 cm H2O...
Definition:
VAC associated with alterations in WBC (< to 4 or ≥ 12) or temperature (< 36 or ≥ 38o C) within 2 days
and
...
VAP Guideline Recommendations
•
Prevention
•
Diagnosis
•
Treatment
Ann Intern Med. 2004;141:305-13.
J Crit Care, 2008
•
Use Oral Route for intubation
May not apply to pts with:
•Maxillofacial trauma/surgery
•ENT surgery
•Difficult intu...
Sub-glottic Secretion Drainage
VAP Guideline Recommendations: Prevention
Sub-glottic Secretion Drainage
Muscedere et al, CCM 2011
•
Subglottic Secretion Drainage
•
Requirement for prolonged mechanical ventilation
May not apply to pts with:
•Nasall...
•
Semi-recumbent positioning at 45 degree angle
May not apply to pts with:
•Patient on vasopressors or undergoing resus...
VAP and Semi-recumbency: The evidence
Outcome: The occurrence of VAP
Patient population:
•
Total of 409 patients studi...
•
Chlorhexidine Oral Antiseptic
May not apply to pts with:
•Chlorhexidine Allergy
•Lack of access to patient’s oral ca...
CHX decontamination compared with no prophylaxis on risk of VAP
VAP Guidelines: Diagnosis
•
No improvement in clinical outcomes (mortality, length of stay, antibiotic use) compared to endotracheal aspirate
•
M...
•
Diagnosis of suspected VAP
•
Endotracheal aspirates with nonquantitative culture
May not apply to pts with:
•
Immu...
Clinical Suspicion of VAP
New or persistent infiltrate on CXR plus 2 of the following:
•
Purulent endotracheal secretio...
VAP Guidelines: Treatment
Treatment of VAP
•
Initial inadequate empiric therapy of VAP is associated with worse outcome
•
Delays in therapy asso...
Impact of adequacy of empiric therapy on outcome
Adequate
Inadequate
p-value*
(n=313)
(n=37)
Died within 14 days
33...
•
Initiation of empiric treatment for VAP
•
Start antibiotics at time of VAP suspicion (do not wait for culture results...
•
Antibiotics for empiric treatment of VAP
•
Single effective agent for each suspected organism
May not apply to pts w...
VAP Guideline Recommendations: Treatment
Monotherapy vs. Combination Therapy: Mortality
•
Choice of antibiotics for empiric treatment of VAP
•
Based on local ICU resistance patterns and patient factors
May ...
•
Discontinuation of empiric antibiotics for VAP
•
If noninfectious etiology of infiltrates is found
OR
•
If signs a...
•
Choice of Antibiotic for Confirmed VAP
•
“A” vs. “B”: No evidence to favor one agent over another
–
Multiple non-in...
MRSA VAP Pneumonia
In the three studies
•
Mortality at different time points reported
•
No effect on mortality was re...
•
Duration of antibiotic treatment for confirmed VAP
•
Maximum of 8 days in patients in whom initial empiric therapy wa...
TREATMENT OF VAP
•
Stop empiric antibiotics for suspected VAP if another reason for patient’s signs & symptoms found
• ...
Thank You
Questions?
QUESTIONS? RAISE YOUR HAND / LEVEZ LA MAIN OR/OU CHAT TO “ALL PARTICIPANTS”
“Taking the Pulse” Poll
08/05/2014 60
Instructions to download certificate
1
2
3
4
5
8
9
Canadian ICU Collaborative Faculty
Paule Bernier, P.Dt., Msc, Présidente, Ordre professionnel des diététistes du Québec; ...
Reminders Rappels

Call is recorded

Slides and links to recordings will be available on Safer Healthcare Now! Commu...
THANK YOU MERCI
This National Call is hosted by:
Supported by:
65
08/05/2014
NationalLatest Updates to the Canadian VAP Guidelines - What's New?
of 63

NationalLatest Updates to the Canadian VAP Guidelines - What's New?

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
Published on: Mar 3, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - NationalLatest Updates to the Canadian VAP Guidelines - What's New?

  • 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 08/05/2014 2
  • 3. Interacting in WebEx: Today’s Tools Interagir dans Webex : outils à utiliser 3 Be prepared to use: - Pointer - Raise hand - CHAT - Text Tool “writing on the slide” - Shape Tools Have you used WebEx before? Avez-vous déjà utilisé WebEx?  YES / OUI NO / NON  Soyez prêts à utiliser les outils : - le pointeur - lever la main - clavardage - Outil textuel pour « écrire sur la diapo » - Outils de forme 08/05/2014 Type your message & click ‘send’ Select ‘send to’
  • 4. 4 Who’s Online? Qui est en ligne? POINTER 08/05/2014
  • 5. What professions are represented? Quelles professions sont représentées? Nurse MD Educator / Quality Improvement Professional Infection Control Administrator / Senior Leader Other POINTER Respiratory Therapist Nutritionist 08/05/2014 5
  • 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
  • 50. • 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
  • 51. • 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
  • 52. MRSA VAP Pneumonia In the three studies • Mortality at different time points reported • No effect on mortality was reported Clinical cure rate
  • 53. • 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
  • 54. 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
  • 55. Thank You Questions?
  • 56. QUESTIONS? RAISE YOUR HAND / LEVEZ LA MAIN OR/OU CHAT TO “ALL PARTICIPANTS”
  • 57. “Taking the Pulse” Poll 08/05/2014 60
  • 58. Instructions to download certificate 1 2 3 4 5 8 9
  • 59. 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) 08/05/2014 62
  • 60. 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 63 08/05/2014
  • 61. THANK YOU MERCI
  • 62. This National Call is hosted by: Supported by: 65 08/05/2014

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