Pulmonary Infection In Critically ill

Patients

KARTIKA JUWITA
Narasumber : dr.Gurmeet Singh, SpPD-KP
Introduction

 Critical illness is a life-threatening multisystem process

that can result in significant morbidity or mortality. In
most patients, critical illness is preceded by a period of
physiological deterioration;
 Two conditions
 critical illness with pneumonia
 pneumonia itself that critical
 Commonly bacteria, but we also have fungi and virus
Critically Ill Patients

Frost P, Wise P. British Journal of Hospital Medicine, October 2013, Vol 68, No 10
Klasifikasi Pneumonia

Etiologi:

- Bakteri

- Virus

- Jamur

 IDSA 2016 : HCAP ditiadakan

Pneumonia Severity
Index
Clinical Pulmonary Infection Score
 threshold of 6 points, the CPIS achieved a sensitivity of 72%, a
specificity of 85%, and an overall accuracy of 79% for the presence of
VAP

 For patients with suspected HAP/VAP, we recommend using clinical

criteria alone rather than using CRP plus clinical criteria, to decide
whether or not to initiate antibiotic therapy (weak recommendation,
low-quality evidence). IDSA, 2016
 In patients with suspected VAP, we recommend including coverage for
S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli in
all empiric regimens (strong recommendation, low-quality evidence).

 If empiric coverage for MRSA is indicated, we recommend either

vancomycin or linezolid
Treatment Recommendations VAP
HAP
 In patients with HAP/VAP caused by a carbapenem-resistant
pathogen that is sensitive only to polymyxins, we recommend
intravenous polymyxins (colistin or polymyxin B) (strong
recommendation, moderate-quality evidence),

 Use antibiotic combinations according to the culture

Acute respiratory distress
syndrome (ARDS)
medical condition occurring in critically ill patients characterized
by widespread inflammation in the lungs. ARDS is not a
particular disease, rather it is a clinical phenotype which may be
triggered by various pathologies such as trauma, pneumonia and
sepsis
ARDS Criteria (Berlin, 2015)

 acute, meaning onset over 1 week or less

 bilateral opacities consistent with pulmonary edema must be present and may be
detected on CT or chest radiograph
 PF ratio <300mmHg with a minimum of 5 cmH20 PEEP (or CPAP)
 “must not be fully explained by cardiac failure or fluid overload,” in the physician’s
best estimation using available information

Treatment: mechanical ventilation

Infeksi Jamur

 Insidensi penyakit akibat infeksi jamur makin meningkat

• Bertambahnya jumlah pasien imunokompromais  keganasan, penyakit hematologi,

HIV, terapi imunosupresan

 Metode dan teknik diagnostik infeksi fungal  makin canggih

Candidiasis

Invasive Candida infections:

 most common nosocomial bloodstream infection  in line related
candidemia*

Pathogen No. of Isolates Incidence (%)

Coagulase-negative staphylococci 3908 31.9
Staphylococcus aureus 1928 15.7
Enterococci 1354 11.1
Candida species 934 7.6

.
Invasive Candidiasis in the ICU

 High morbidity (extent LOS 22 days) and mortality


 Difficult to diagnose (cultures positive in only ~ 50%).

 We can define ICU risk factors for candidiasis and target the population at highest risk
with empiric Rx.

 Recent increase in Candida spp. resistant to fluconazole.

Eur J Clin Microbiol Infect Dis. 2004:23; 739-744.

 Major Risk Factors of Candidiasis

 Prior antibiotic use,

 Central venous catheters,
 Total parenteral nutrition,
 Major surgery (abdominal) within one week,
 Steroids, Immunosuppression.

ICU length of stay: the rate of infections rising rapidly after 7-10 days
Candida score
(colonization vs infection)
 Severe sepsis (2 points)
 Surgery (1 point)
 TPN (1 point)
 Multifocal candida colonization (1 point)

 patients staying for more than 7 days, only 13 of 565 (2,3%) patients with score <3
develop candidiasis: NPV 98%

Crit care med 2006,34:730-737

Laboratory Diagnosis: Candida
 Microbiology methods:
 Recovery of Candida species from sterile sites (ex. blood, peritoneal fluid) is diagnostic of IC and
recovery from multiple non-sterile sites is highly suggestive of IC in the at-risk patient.
 Blood culture is positive in less than 50% of patients with autopsy proven IC.

 Molecular methods:
 early identification e.g PNA FISH

 Serological methods:
 early diagnosis e.g. 1,3 beta D glucan assay.

 Histopathologic methods
 Therapy of IC in the ICU
 A definitive diagnosis of IC may be delayed when the clinical and
laboratory tools readily available to clinicians
 A delay in diagnosis will unfortunately result in a delay in
initiation of antifungal therapy  increased mortality
 in the patient with suspected Candida infection, treatment may
need to be initiated on the basis of individual patient factors
before a definitive diagnosis is made.
 fluconazole, itraconazol

*Morrel M et al. 2005. Antimicrob Agents Chemother. 49(9): 3640-5.

*Garey K et al. 2006. Clin Infect Dis. 43: 25-31.
Aspergillosis
Aspergillus species are found in :

 Soil
 Air; spores may be inhaled
 Water / storage tanks in hospitals etc
 Food
 Compost and decaying vegetation
 Fire proofing materials
 Bedding, pillows
 Ventilation and air conditioning systems
 Computer fans
 Invasive aspergillosis: diagnosis

 Radiology: chest X-ray and CT: no halo sign

 Microbiology
 Respiratory secretions: BAL/biopsy
 Direct microscopy
 culture
 Serological surveillance
 ELISA for galactomannan

 PCR
Empiric Therapy
 Hemodynamic stability with no azole resistance: fluconazole
(alt: echinocandins, voriconazole, amphotericine B)
 Hemodinamic stability with azole resistance: echinocandins (alt:
LFAB)
 Hemodinamic unstability: echinocandins (alt: LFAB)
Echinocandine: caspofungin, micafungin, anidulafungin; LFAB: lipid formulation of
Amphotericine B
Fluconazole loading 800mg then 400mg daily
Micafungin 100mg qd, caspofungin loading dose 70mg then 50mg qd; anidulafungin
loading dose 200mg then 100mg qd
Pneumocystis Pneumonia

 not commonly found in the lungs of healthy people, but, being a

source of opportunistic infection
 People with cancer undergoing chemotherapy, HIV/AIDS, and the
use of medications that suppress the immune system
 The chest radiographic findings may be normal in patients with
early mild disease. Diffuse bilateral infiltrates extending from the
perihilar region
Pneumocystis Pneumonia

 LDH levels are usually elevated (>220 U/L) in patients with P

jiroveci pneumonia (PJP). They are elevated in 90% of patients
with PJP who are infected with HIV.

 propylaxis and treatment: co-trimoxazole

(trimethoprim/sulfamethoxazole),
Viral Pneumonia

 less common
 not specific symptoms
 respiratory syncytial virus (RSV) and cytomegalovirus (CMV)
 Immunofluorescence assay and enzyme-linked immunosorbent
assay (ELISA) are available for the diagnosis of HSV, RSV, influenza
viruses A and B, PIV, CMV, and other respiratory viruses
 Ribavirin (RSV), Ganciclovir (CMV)