Srinagarind Med J 2010: 25 (Suppl)

HAP, VAP and HCAP Guidelines: from Guidelines to Clinical

Practice

nosocomial infection
nosocomial pneumonia urinary tract
infection, blood stream infection skin and soft
tissue infection nosocomial pneumonia
hospital acquired pneumonia (HAP)

48 ventilator associated
pneumonia (VAP)
48
HAP VAP
health care associated pneumonia (HCAP)

2 90
nursing home chemotherapy,
wound care chronic dialysis 30

1
nosocomial pneumonia
morbidity mortality



2552 nosocomial

infection 31 12
VAP 5
HAP nosocomial
infection
(guidelines)

nosocomial pneumonia

aspiration
oropharynx trachea
cuff pressure endotracheal tube
aspiration nasal sinus gastric
content endogenous pathogens
colonization inhalation
exogenous pathogens health care
worker
ventilator circuit nebulizer
biofilms endotracheal tube ( 1)

2

26 2553

87

SYMPOSIUM

Srinagarind Med J 2010: 25 (Suppl)

Sources of microorganisms causing HAP and VAP

Endogenous

SYMPOSIUM

Oropharynx, Trachea,
Nasal carriage, Sinusitis,
Gastric fluids

Exogenous
Aspiration

Inhalation

Health care worker,

Ventilatory circuits,
Nebulizers, Biofilms

HAP and VAP

Blood

I
1 HAP VAP2

empiric antibiotic

new infiltrates 2 3
1) 38.3 oC, 2) leukocytosis (
12,000 /)
leukopenia ( 4,000 /
), 3) (purulent
secretion)1 69
75
Grams stain
quantitative
colony count semi-quantitative

colonization
lung infiltrates congestive
heart failure, atelectasis, pulmonary hemorrhage,
pulmonary drug reaction, pulmonary thromboembolism,
ARDS

88

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clinical
pulmonary infection score (CPIS)3
6
PaO2/FiO2

1 0 2
0 12
6

77
42 invasive diagnosis
bronchoscopy bronchoalveolar lavage
fluid (BALF) 4
Grams stain
bronchoscopy


biomarkers C-reactive protein procalcitonin
VAP4

Srinagarind Med J 2010: 25 (Suppl)

1 The modified clinical pulmonary infection score (CPIS)3
CPIS points
0
1
Tracheal secretions
Rare
Abundant
Chest X-ray infiltrates
No infiltrate
Diffused
> 36.5 and < 38.4
Temperature, oC
Leukocytes count, per mm3 > 4,000 and < 11,000
> 240 or ARDS

Microbiology
(tracheal aspiration)

Negative

> 39 or < 36
< 4,000 or > 11,000 +
band form > 500
< 240 and no evidence
of ARDS
Positive

Total score 0-12, if >6 likelihood of pneumonia

2


early onset 5

late onset
5 1

90 5
HCAP
immunosuppressive therapy
late onset

P.aeruginosa, K.pneumoniae
(ESBL), Acinetobacter species MRSA
early
onset
S.pneumoniae, H.influenzae, Methicillin-sensitive
S.aureus antibiotic-sensitive enteric gram negative
bacilli (E.coli, K.pneumoniae, Enterobacter species,
Proteus species Serratia marcescens)1

HAP VAP
HAP
21.8 1,000

(admission) VAP 28.3

5 HAP
VAP A.baumannii
28.2 , Pseudomonas spp.
17.8 K.pneumoniae
7.7, MRSA 7.6 E.coli 2.85
A.baumannii

2552 HAP 0.5 1,000

(hospital day)
P.aeruginosa
29.7 , A.baumannii 22.6
K.pneumoniae
19.4, MRSA 9.0, E.coli 4.5, Enterobacter
spp. 4.5, Xanthomonas maltophilia 4.5,
Proteus mirabilis 1.9 Serratia marcescens
1.9 VAP 13.6 1,000
(ventilator day)
A.baumannii 26.9
P.aeruginosa 25
K.pneumoniae 15.4, Enterobacter spp.
8.8, MRSA 7.2, Xanthomonas maltophilia
7.2, E.coli 4.8 Serratia spp.
2.4
P.aeruginosa ceftazidime
26 2553

89

SYMPOSIUM

PaO2/FIo2, mmHg

> 38.5 and < 38.9

< 4,000 or > 11,000

2
Abundant+purulents
Localized

SYMPOSIUM

Srinagarind Med J 2010: 25 (Suppl)

58, piperacilin/tazobactam 72,
imipenem 26, meropenem 17,
netilmicin 96 colistin P.aeruginosa
99 A.baumannii
A.baumannii
cefoperazone/sulbactam 17, imipenem
5, meropenem 5 netilmicin
42 colistin A.baumannii
99 tigecycline A.baumannii
85 K.pneumoniae
K.pneumoniae ESBL
ceftriaxone 98 K.pneumoniae
ESBL carbapenem
imipenem meropenem 100

ATS IDSA guidelines

2 1
early onset
limited spectrum
ceftriaxone antipneumococcal fluoroquinolone
(levofloxacin moxifloxacin) ampicillin/ sulbactam
ertapenem
late onset
board spectrum
combination antipseudomonal cephalosporin
(cefepime, ceftazidime) antipseudomonal
carbapenem (imipenem meropenem) -lactam/
-lactamase inhibitor (piperacillin/tazobactam
cefoperazone/sulbactam) antipseudomonal
fluoroquinolone (ciprofloxacin levofloxacin)
aminoglycosides (amikacin, gentamicin tobramycin)
MRSA
gram-positive cocci in cluster

ceftazidime 2 8 , imipenem 500

6 1 8 , meropenem
1 8 , piperacillin/tazobactam 4.5
6 , cefoperazone/sulbactam 2 3 12
, amikacin 20 //, levofloxacin
750 , moxifloxacin 400
90

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, ciprofloxacin 400 8 , vancomycin

15 / 12 linezolid 600
12

Asian guidelines Acinetobacter

spp.

sulbactam containing antibiotic VAP
HAP6
Asian guidelines7
1. Early onset HAP:
third generation cephalosporin
(ceftriaxone cefotaxime), fluoroquinolone (levofloxacin
moxifloxacin), -lactam/ -lactamase inhibitor
(amoxicillin/clavulanic acid ampicillin/sulbactam),
ertapenem -lactam monobactam
(aztreonam) clindamycin
2. Late onset HAP: 2
third generation cephalosporin (ceftazidime
cefepime), carbapenem (imipenem meropenem),
-lactam/ -lactamase inhibitor (piperacillin/
tazobactam) fluoroquinolone (ciprofloxacin,
levofloxacin), aminoglycoside (amikacin, gentamicin,
tobramycin) gram-positive cocci
in duster glycopeptides (vancomycin
teicoplanin), linezolid
Acinetobacter spp.
sulbactam containing
regiments cefoperazone/sulbactam ampicillin/
sulbactam fluoroquinolone (ciprofloxacin
levofloxacin), aminoglycoside (amikacin, gentamicin,
tobramycin)
3. Early onset VAP:
late onset HAP antipseudomonal cephalosporin
ceftazidime
fourth generation cephalosporin
(cefepime cefpirome) 2
aminoglycoside
fluoroquinolone fluoroquinolone
L.pneumophila
aminoglycoside
aminoglycoside amikacin

Srinagarind Med J 2010: 25 (Suppl)

oxygen saturation
(white blood
cell count)

HAP
VAP 7 P.aeruginosa,
A.baumannii S.maltophilia
14
MRSA, P.aeruginosa ,
Acinetobacter spp. gram-negative
bacilli ESBL 14 21
Asian guidelines
6

(de-escalating therapy)7

2 first-line (1) second-line (2)

Resistant pathogens
Rank
Antibiotic regimen
MRSA
1
Vancomycin or teicoplanin
2
Linezolid or tigecycline
MDR P.aeruginosa
1
Piperacillin/tazobactam or carbapenems plus/minus aminoglycosides
or fluoroguinolones (ciprofloxacin)
2
Polymyxin B or colistin plus/minus ciprofloxacin
MDR Acinetobacter spp. 1
Cefoperazone/sulbactam and/or tigecycline
2
Polymyxin B or colistin
K.pneumoniae ESBL
1
Carbapenems or tigecycline
2
Piperacillin/tazobactam
E.coli ESBL
1
Carbapenems or tigecycline
2
Piperacillin/tazobactam
26 2553

91

SYMPOSIUM

gentamicin tobramycin netilmycin

sulbactam containing regimen Acinetobacter
spp.

4. Late onset VAP:

late onset HAP antipseudomonal
cephalosporin piperacillin/tazobactam
carbapenem (imipenem meropenem)
P.aeruginosa
Acinetobacter spp. K.pneumoniae
ESBL Acinetobacter spp.

sulbactam containing regimens cefoperazone/
sulbactam ampicillin/sulbactam fluoroquinolone (ciprofloxacin levofloxacin), aminoglycoside (netilmycin amikacin)

first-line second-line 37

continuous intravenous drip
-lactam time above MIC
colistin

empiric antibiotic
2 3 1,7

SYMPOSIUM

Srinagarind Med J 2010: 25 (Suppl)

HAP VAP
HAP VAP
morbidity
mortality
HAP VAP 8
VAP9, 10
2
1. Evidence-based practice guidelines
VAP
- Non-invasive mechanical ventilation

- Orotracheal intubation orogastric
tube nasotracheal intubation
nasogastric tube nosocomial
sinusitis VAP
- Elevated head of the bed 30 45
85 11

8 supine 0
34
- Stress ulcer bleeding prophylaxis

coagulopathy
GI bleeding mortality
5 H2 blocker
GI bleeding sucralfate
H2 blocker sucralfate early onset
VAP sucralfate late onset
VAP H2 blocker9
H2 blocker stress ulcer
bleeding prophylaxis
- Daily sedation interruption and weaning
protocol12 daily sedation interruption

7.3 4.9 daily sedation
interruption
VAP
self-extubation
- Decontamination of oropharynx 0.2%
chlorhexidine systematic review meta-analysis
92

26 2553

oral antiseptic
VAP 44
endogenous source 13
- Hand washing antiseptic alcohol
hand-rub
exogenous source
- Monitor cuff pressure 18 25
minimal occluding pressure
aspiration
2. Device-based technologies
- Continuous aspiration of subglottic secretions
(CASS) aspiration
endogenous source
VAP prolonged
mechanical ventilation14
- Silver-coated endotracheal tube15
endotracheal tube internal bio-layer bacterial
colonization biofilm
silver-coated endotracheal tube
VAP silver-coated endotracheal tube
VAP 4.8 uncoated ET tube
VAP 7.5
- Ultrathin cuff endotracheal tube
high-volume low-pressure cuff leakage
cuff tracheal injury
VAP
bundle of care VAP
bundle of care
Institute for health care improvement (IHI)
ventilator bundle of care16

VAP , GI bleeding deep
venous thrombosis IHI ventilator bundle
of care 4 1) elevated head of
the bed 30 45 , 2) daily sedation vacations
assessment for extubation, 3) peptic ulcer prophylaxis
4) deep venous thrombosis prophylaxis
IHI ventilator bundle of care

(adherence) bundle of care
2 3 90
100

Srinagarind Med J 2010: 25 (Suppl)

morbidity mortality

bundle of care

1. The American Thoracic Society and the Infectious

Disease Society of America. Guidelines for the
management of adults with hospital-acquired,
ventilator-associated, and healthcare-associated
pneumonia. Am J Respir Crit Care Med 2005; 171:388416.
2. Rotstein C, Evans G, Born A, Grossman R, Light
RB, Magder S, et al. Clinical practice guidelines for
hospital-acquired pneumonia and ventilator-associated
pneumoniea in adults. Can J Infect Dis Med Microbiol
2008; 19:19-53.
3. Pugin J, Auckenthaler R, Mili N, Janssens JP, Lew PD,
Suter PM. Diagnosis of ventilator-associated pneumonia
by bacteriologic analysis of bronchoscopic and non
bronchoscopic blind bronchoalveolar lavage fluid.
Am Rev Respir Dis 1991; 143:1121-9.
4. Rea-Neto A, Youssef NCM, Tuche F, Brunkhorst F,
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literature. Crit Care 2008; 12:R56.
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hospital-acquired pneumonia and ventilator-associated
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7. Song JH and the Asian HAP working group. Treatment
recommendations of hospital-acquired pneumonia in
Asian countries: first consensus report by the Asian HAP
Working Group. Am J Infect Control 2008; 36: S83-S92.
8. Thai Clinical practice guidelines for management
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ventilator-associated pneumonia. The Thai Society of
Critical Care Medicine Bulletin Vol 15 No.1 January
February 2007.

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VAP 10/1,000 ventilator

day 2 3 / 1,000 ventilator day

8 1 17, 18
ventilator bundle of care
IHI ventilator bundle of care oral
care 0.12% chlorhexidine 4
VAP 19
IHI ventilator bundle of care
European care bundle for VAP20
5 VAP 1)
ventilator circuit , 2) alcohol hand hygiene,
3) educated and trained staff, 4) sedation vacation and
weaning protocol 5) oral care with chlorhexidine
VAP

..2553
KKU VAP bundle of care VAP
5
1) hand washing antiseptic alcohol hand-rub,
2) elevated head of the bed 30 45
85 , 3) daily sedation interruption
weaning protocol, 4) optimized of endotracheal tube
cuff pressure 18 25 5) decontamination of oropharynx 0.2% chlorhexidine
bundle of care



VAP

SYMPOSIUM

Srinagarind Med J 2010: 25 (Suppl)

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