Dr. S. K.

Jindal
www.jindalchest.com
 Hospital Acquired Pneumonias

Occurrence of pneumonia in a hospitalized patient when the infecting

organisms are neither present nor incubating at the time of admission.

Pneumonia occuring in a ventilated patient is called a ventilator associated

pneumonia (VAP).
 When to suspect RTI ?

• Clinical: General Respiratory

• Radiological shadows

• Laboratory abnormalities
 Clinical Diagnosis

New or progressive lung infiltrates (Plus 2 of the following criteria) after

48 hours of hospital admission:

» Fever

» Purulent sputum

» Leucocytosis
 Chest Roentgenography

• New infiltrates / opacities

• Alveolar shadows – consolidation (Lobar/segemental/ others)
• Pleural effusion / pneumothorax
• Air cysts / cavities
• Interstitial / miliary shadows
• Hilar L.N. ± infiltrates
False-negative chest radiographs

• Early course of disease

• PCP pneumonia / miliary TB

• Dehydration

• Neutropenia/rare
False-positive chest radiographs

• Interstitial lung diseases

• Vasculitis

• Atelectasis

• Congestive heart failure

• Pulmonary infarcts

• Malignancies

• Miscellaneous
 General Laboratory Tests
• Leucocytosis (polymorphonuclear)

• Raised ESR

• Arterial blood gases

• S. electrolytes; liver & renal function tests

• Blood sugar

• H.I.V. serology

• Blood cultures

• Others
 “Pulmonary Samples” for Diagnosis
• Sputum / tracheal secretions
• Bronchoscopic

- Washings

- Bronchial / bronchoalveolar lavage

- Biopsy (bronchial / TBLB)

- Needle aspiration
• Transthoracic needle biopsy
• Transtracheal aspiration
• Pleural aspirate / biopsy
• Thoracoscopic specimens
 Sputum/ trach sec. examination
• Quantity

• Naked eye examination

• Cytological

Lower airways >25 PMN / field on low power <10 epithelial cells/field

Malignant cells Parasites, fungi, etc.

• Microbiological

Gram staining

Culture and sensitivity

 “Good Quality” sample

• Before antibiotic treatment

• Prior mouth rinse

• Deep cough

• Purulent, thick part (minimal saliva)

• Early processing
 Approach to Diagnosis

Clinical Microbiological

Empirical Invasive

Combined
 Scoring Systems

1. Clinical Pulmonary Infection score (CPIS)

Each criteria worth 0-2 points:

• Fever
• Quantity and purulence of tracheal secretions
• Oxygenation

Type of radiographic abnormalities (Results of sputum culture & gram stain)

2. Bacterial index by Pugin et al.

3. Modified CPIS
 CPIS Clinical Criteria
Points
Variables 0 1 2
Temperature °C >36.1 to <38.4 >38.5 to <38.9 >39 to < 36

WBC count /µ L >4,000 to < < 4,000 to >

11,000 11,000

Secretions Absent Present, Present, purulent

nonpurulent
PaO2/fraction of >240 or ARDS <240 and no
inspired oxygen ARDS
Chest No infiltrate Diffuse or patchy Localized
radiography infiltrate infiltrate
Microbiology No or light Moderate/heavy
growth growth; add
1point for same
organism on
Gram stain
 National Nosocomial Infection Surveillance
System
Radiographic Two or more serial chest radiographs with
new or progressive and persistent infiltrate/or cavitation or consolidation;
(one radiograph sufficient in patients without underlying cardiopulmonary disease)
Clinical One of the following:
Fever > 38o C (>100.4o F) with no other recognized cause
WBC count <4,000/ µ L or > 12,000 µ L
For adults > 70 yr old, altered mental status with no other recognized cause
And at least two of the following:
New-onset purulent sputum: change in character, or increase in respir. secretions
New-onset or worsening cough, dyspnea, or tachypnea
Rales or bronchial breath sounds
Worsening gas exchange, increased oxygen requirements, and ventilatory support
Microbiology (optional): Positive culture result (one): blood (unrelated to other
source),pleural fluid/ quantitative culture by BAL or PSB, >5% BAL-obtained cells
contain intracellular bacteria
 Risk factors for MDR Pathogens

• Antibiotics in the preceding 90 d

• Hospitalization in preceding 90 d

• Current hospitalization > 5 d

• Duration of mechanical ventilation > 7 d

• History of regular visits to an infusion or dialysis centre

• Residence in a nursing home or extended-care facility

• Immunosuppressive disease or therapy

• High frequency of antibiotic resistance in the community or the ICU

From American Thoracic Society and Trouillet et al

 Problems with clinical approach

Two thirds of all patients with clinical diagnosis of VAP may not meet
microbiological criteria for infection

Clinical definition – not specific

Many patients with clinical VAP may have non-infectious etiologies

But………

Mortality in VAP is reduced when prompt and adequate empiric therapy is

initiated.

Luna et al 1997

Kollef et al
1999
Clinical approach to VAP
 Invasive Approach

Quantitative, Bacterial diagnosis

Tightly protocolized therapeutic decisions based on results of direct

examination of distal pulmonary samples and of quantitative cultures
 Techniques

Bronchoscopic Nonbronchoscopic

• Proper selection of Poor site selection

sample site
• Complications: Occasional Less invasive
 Protected – Specimen – Brush technique

1. Use of FOB

2. Double lumen catheter brush

3. Use of a brush to calibrate the volume of secretion

4. Quantitative cultures
Quantitative Culture - Diagnostic threshold

Pathogens: 105 – 106 CFU/mL

Contaminants <104 CFU/mL

 PSB (0.001-0.01mL): Presence of 103 CFU represents

105 – 106 CFU/mL

 BAL (1mL): 104 CFU/mL represents

105 – 106 CFU/mL

Invasive strategy for VAP
 Immuno suppressed Host
(eg Transplant patients)
Diagnostic clues

1. Underlying disease

2. Known microbiological spectrum

3. Radiological features

4. Respiratory secretions: Tracheal, BAL

5. Biopsies

6. Indirect: Biochemical, serological

7. Therapeutic “trial”/Empiric therapies

 Summary

1. Diagnosis of VAP is mostly based on clinical criteria/scoring system

2. Empiric treatment need not wait for the microbiological diagnosis made
from BAL, PSB etc.

3. Diagnosis in the immuno suppressed patients requires invasive tests

(FOB, aspiration cytology, biopsy)