Allen Widysanto

Introduction
HOSPITAL-ACQUIRED PNEUMONIA Pneumonia that occurs 48 hours or more after admission, which was not incubating at the time of admission VENTILATOR-ASSOCIATED PNEUMONIA Pneumonia that arises more than 48-72 hours after endotracheal intubation HEALTHCARE ASSOCIATED PNEUMONIA (HCAP) Any patients who was hospitalized in an acute care hospital for two or more days within 90 days of the infection; resided in a nursing home or long-term care facility; received recent IV antibiotic therapy, chemotherapy or wound care within the past 30 days of the current infection; or attended a hospital or hemodyalisis clinic

Four major principles underlie the management of HAP, VAP and HCAP
Avoid untreated or inadequately treated HAP, VAP or HCAP, because the failure to initiate prompt appropriate and adequate therapy has been a consistent factor associated with increased mortality

Recognize the variability of bacteriology from one hospital to another, spesific sites within the hospital, and from one time period to another, and use this information to alter the selection of an appropriate antibiotic treatment regimen for any spesific clinical setting

Avoid the overuse of antibiotics by focusing on accurate diagnosis, tailoring therapy to the results of lower respiratory tract cultures and shortening duration of therapy to the minimal effective period

Apply prevention strategies aimed at modifiable risk factors

PATHOGENESIS
3 CRITICAL FACTORS

COLONIZATION OF THE OROPHARYNX WITH PATHOGENIC ORGANISM ASPIRATION OF THESE SECRETION FROM OROPHARYNX INTO THE LOWE R RESPIRATORY TRACT HOST DEFENSE MECHANISM

How do you diagnose?

New infiltrate or changing radiographic

Systemic inflammation Increased purulent secretion

Differential diagnosis
PULMONARY EDEMA

ARDS

LUNG CONTUSION

ATELECTASIS

STRONG CONFIRMATI ON

CULTUR E

THERAPY

ANTIBIOTIC THERAPY Obtain lower respiratory tract culture Start broad-spectrum empiric antibiotic therapy Streamline the regimen to cover only pathogen present on culture S T O P antibiotics if culture are negative S T O P all treatment after 7-8 days

Initial Therapy for Serious

HAP and sepsis: 2 most common, most serious

Nosocomial Infection

infections in ICU, are associated with high mortality rates. increases mortality.

Inadequate therapy for HAP and severe sepsis Empiric broad-spectrum therapy must be

initiated at the first suspicion of serious infection to ensure adequate coverage of all likely pathogens.
Kollef MH. Clin Infect Dis 2000;31(Suppl 4):S131-S138. Kollef MH. Chest 1999;115:462-474. Richards MJ et al. Crit Care Med 1999;27:887-892. Van der Poll T. Lancet Infect Dis 2001;1:165-174. Bernard GR et al. N Engl J Med 2001;344:699-709. HAP= hospital-acquired pneumonia

DE-ESCALATION THERAPY
Stage 1 Administer the broadest-spectrum antibiotic therapy to improve outcomes
dysfunction, stay).

(decrease mortality, prevent organ and decrease hospital length of

Stage 2 Focus on de-escalation as a means to minimize resistance and improve costeffectiveness

Trademark of Merck & Co., Inc., Whitehouse Station, NJ.

DE-ESCALATION THERAPY
Stage 1 Administer the broadest-spectrum antibiotic therapy to improve outcomes
dysfunction, (decrease mortality, prevent organ and decrease length of hospital stay)

Stage 2 Focus on de-escalation as a means to minimize resistance and improve costeffectiveness

What causes treatment failure?

Antibiotic resistance
PRIMER SECONDARY

Ineffective therapy Inadequate dosing Poor penetration to the lung Anatomic problem (lung

abscess/empyema)