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Prevention of
Lower Respiratory
Tract Infections
1. Explain the relevance of pneumonia in
health care institutions.
2. Outline elements for defining HAI
pneumonia.
3. Identify risk factors for pneumonia.
4. Describe the measures for prevention
of pneumonia.
December 1, 2013
Learning objectives
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• 35-40 minutes
December 1, 2013
Time involved
3
• Pneumonia causes morbidity and mortality and
increased utilisation of resources
• Prevention is vital
• Prevention includes
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•
•
•
•
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•
hand hygiene
use of gloves
daily assessment of weaning from a ventilator
elevation of the bed head
orotracheal intubation
oral care with an antiseptic solution
cleaning and disinfection of equipment
December 1, 2013
Key points
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• In healthy individuals the lower
respiratory tract is sterile
• Cough reflex, respiratory mucosa,
secretions, and immunity prevent
microorganisms in the LRT
December 1, 2013
Introduction
• Impaired conditions of patients and
incorrect practices contribute to
healthcare-associated pneumonia
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• Pneumonia accounts for 11% - 15% of HAI and
25% of infections in ICUs
• Highest mortality among HAIs
• Postoperative pneumonia - a common
complication of surgery
• Ventilator–associated pneumonia occurs in 828% of patients
• Prolongs hospitalisation and antibiotic use
• Microorganisms often multidrug-resistant
December 1, 2013
The problem
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DEFINITION
• LRT infection that appears during
hospitalisation in a patient who was not
incubating the infection at admission
December 1, 2013
Healthcare-associated
Pneumonia
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It is diagnosed by the following:
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•
•
•
•
rales or bronchial breath sounds
fever
purulent sputum, cough, dyspnoea, tachypnea
relevant radiologic changes
preferably, microbiological diagnosis from bronchial
lavage, transtracheal aspirate, or protected brush
culture
December 1, 2013
Diagnosis
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There are three pneumonia categories:
•PNU1
• X-ray changes and clinical signs and symptoms
laboratory findings
•PNU2
• X-ray changes, clinical signs and symptoms,
microbiological results
•PNU3
• pneumonia in immuncompromised
December 1, 2013
Categories*
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For surveillance purposes, many
practitioners use the pneumonia definition
published by the U.S. Centers for Disease
Control and Prevention’s National
Healthcare Safety Network (NHSN)
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Surveillance
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• Impairs normal removal of
mucus and
microorganisms from the
lower airway
• H2 blocking agents
associated with
colonisation of
gastrointestinal tract and
oropharynx
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Mechanical ventilation
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Microorganisms may be introduced into the LRT via
contaminated equipment or staff hands
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Pathogenesis
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Condition of
patient
Therapy
Severely ill, e.g., septic shock
Surgery (chest/abdomen) injuries
Age
Cardiopulmonary disease
Cerebrovascular accidents
Lung disease
Coma
Heavy smoker
Sedation
General anaesthesia
Tracheal intubation
Tracheostomy
Enteral feeding
Mechanical ventilation
Broad spectrum antibiotic
H2 blockers
Immunosuppressive and cytotoxic drugs
December 1, 2013
Risk Factors
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Early-onset
pneumonia
Four days of
admission (in ICUs
or after surgery)
Late-onset
pneumonia
More than 4 days
after admission
December 1, 2013
Time of onset
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Early-onset pneumonia
Late-onset pneumonia
Streptococcus pneumoniae
Pseudomonas aeruginosa
Haemophilus influenzae
Acinetobacter spp.
Moraxella catarrhalis
Enterobacter spp.
Methicillin- sensitive
Staphylocoocus aureus
Methicillin- resistant
Staphylococcus aureus
Influenza
Respiratory syncytial or other
respiratory viruses
Multidrug - resistant organisms
Candida spp.
Aspergillus spp.
December 1, 2013
Etiological agents
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• Many late-onset VAPs caused by multi-resistant
microorganisms
• In immunocompromised patients microbes:
• Viruses (RSV, influenza)
• Fungi (Candida spp. and Aspergillus)
• Legionella
December 1, 2013
Considerations
• from air conditioning or water supplies
• Pneumocystis carinii (AIDS patients)
• Mycobacteria
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Other
25%
Candida
3%
E coli
5%
Klebsiella
8%
Acinetobacter
9%
S. Aureus
25%
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NHSN survey - causes of VAP in
USA
Pseudomonas
17%
Enterobacter
8%
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Other
30%
S. Aureus
16%
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Survey in 12 European
countries 2008*
Pseudomonas
18%
Candida
8%
E coli
9%
Klebsiella
8%
Enterobacter
Acinetobacter 7%
4%
*European Centre for Disease Prevention and Control (ECDC)
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Recommendations are designed to avoid the three
mechanisms by which pneumonia develops:
• aspiration
• contamination of the aerodigestive tract
• contaminated equipment
December 1, 2013
Prevention
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• Treat lung disease prior to surgery
• Elevate head of the bed
• Avoid unnecessary suctioning
• Provide regular oral cavity care
• Encourage deep breathing and coughing
• Provide pain therapy (non-sedative)
• Use percussion and postural drainage to
stimulate coughing
• Encourage early mobilisation
December 1, 2013
Prevention of postoperative
pneumonia
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• Hand hygiene before and after contact with
patient or respiratory secretions
• Gloves when handling secretions
• Sterile gloves for aspiration and tracheostomy
care
• Sterile suction catheter
• Daily assessments of readiness to wean.
• Minimise the duration of ventilation and
noninvasive whenever possible
December 1, 2013
Prevention of VAP - 1
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• Elevate the head of the bed
• Avoid gastric over-distension
• Avoid unplanned extubation
• Orotracheal intubation
• Avoid H2 agents and proton pump inhibitors
• Regular oral care with an antiseptic solution
• Sterile water to rinse respiratory equipment.
• Remove condensate, keep the circuit closed
• Change ventilator circuit only when necessary
December 1, 2013
Prevention of VAP - 2
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• Store and disinfect respiratory
equipment
• Surveillance for VAP
• Direct observation of
compliance
• Educate healthcare personnel
• Establish antibiotic regimens in
accordance with the local
situation
December 1, 2013
Prevention of VAP - 3
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1. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R.
Guidelines for preventing health-care associated
pneumonia, 2003: recommendations of CDC and the
Healthcare Infection Control Practices Advisory
Committee. MMWR Recom Rep 2004; 53:1-36.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr53
03a1.htm
2. American Thoracic Society; Infectious Disease Society
of America. Guidelines for the management of adults
with hospital-acquired, ventilator-associated, and
healthcare-associated pneumonia. Amer J Respir Crit
Care Med 2005; 171:388-416.
http://ajrccm.atsjournals.org/ cgi/reprint/171/4/388
December 1, 2013
References - 1
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1. Coffin S, Klompas M, Classen D et al. Strategies to
prevent ventilator- associated pneumonia in acute
care hospitals. Infect Control Hosp Epidemiol 2008;
29:S31-S40.
2. Kollef M. Prevention of hospital-associated
pneumonia and ventilator– associated pneumonia.
Crit Care Med 2004; 32:1396-1405.
December 1, 2013
References - 2
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1. Allegranz B, Nejad SB, Combescure C, Graafmans W,
Attar H, Donaldson L, Pittet P. Burden of endemic
health-care-associated infection in developing
countries: systematic review and meta- analysis. Lancet
2011; 377: 228 – 241.
2. Ding J-G, Qing-Feng S, Li K-C, Zheng M-H, et al.
Retrospective analysis of nosocomial infections in the
intensive care unit of a tertiary hospital in China during
2003 and 2007. BMC Infect Dis 2009; 9:115.
December 1, 2013
Further reading
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1.
2.
Most cases of hospital pneumonia are not preventable.
T/F?
The main strategy to prevent VAP is
a)
b)
c)
d)
3.
Treatment of respiratory diseases
Routine culture of patients
Minimise duration of mechanical ventilation
Isolation of infected patients in ICU
December 1, 2013
Quiz
Regarding prevention of VAP, which is incorrect?
a)
b)
c)
d)
Change circuits of mechanical ventilation only if is necessary
Elevate head of the bed if not contraindicated
Gloves when handling respiratory secretions
Use of antimicrobial prophylaxis always in patients with
mechanical ventilation
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• IFIC’s mission is to facilitate international networking in
order to improve the prevention and control of
healthcare associated infections worldwide. It is an
umbrella organisation of societies and associations of
healthcare professionals in infection control and related
fields across the globe .
• The goal of IFIC is to minimise the risk of infection within
healthcare settings through development of a network of
infection control organisations for communication,
consensus building, education and sharing expertise.
• For more information go to http://theific.org/
December 1, 2013
International Federation of
Infection Control
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