Title: Prediction of Early Ventilator Associated Pneumonia using Clinical Pulmonary Infection Score and C-Reactive Protein- A Prospective Observational Study

Authors: Dr Basanth Kumar S, Dr Mohammad Fakruddin, Dr Neelkanth MG, Dr Padmini SN

 DOI:  https://dx.doi.org/10.18535/jmscr/v5i12.156

Abstract

Background & Objectives: Ventilator associated pneumonia (VAP) is an important form of hospital acquired pneumonia (HAP), specifically developing in a mechanically ventilated patient more than 48 hours after tracheal intubation. The overall or crude mortality associated with VAP ranges from 40% to 70% varying with underlying illness. Recent studies have shown that Clinical pulmonary infection score and CRP are valuable tool in detection of early VAP. The aim of the study  was  correlate clinical pulmonary infection score and c-reactive protein in the prediction of early ventilator associated pneumonia

Methods: In this study we have taken 30 patients who were above 18 yrs diagnosed to have Early Ventilator associated pneumonia and subjects on immunosuppressive therapy, chemotherapy and AIDS, Patient intubated outside hospital and refered were excluded.  Serial CRP levels were measured later CPIS was calculated With the onset of chest infilterate, ET Tube Aspirate culture was obtained for confirmation of VAP.

Results: 30 patients were enrolled. CPIS Score was calculated in 22 patients who developed early VAP which is confirmed by ET tube aspirate culture and sensitivity. CPIS Score of > 6 in cases who developed early VAP which is confirmed by ET Culture and sensitivity was statistically significant  on  Day 4 with p value of  0.016 , But it was not significant on Day 3 and 5 .Over all statistical analysis of CPIS Value of >6 in 18 patients who developed early VAP was significant (P value 0.003). There was serial rise in the titers of CRP levels but CRP levels did not show any stastical significance with CPIS score in VAP patients.

Conclusion: Study showed when the CPIS exceeded 6, there was an association with the presence of pneumonia in mechanically ventilated patients which was confirmed by ET tube aspiration culture. serum CRP is an easy, available and cheap test so serial rise in titres of CRP in mechanically ventilated  patients  along with CPIS helps in the early diagnosis of pneumonia and aggressive treatment to prevent mortality and morbidity.

Keywords: Ventilator associated pneumonia; C reactive protein; Clinical pulmonary infection score; Hospital acquired pneumonia.

References

  1. Hina Gadani,Arun Vyas, and Akhya Kumar Kar study of ventilator-associated pneumonia: Incidence, outcome, risk factors and measures to be taken for prevention : Indian J Anaesth. 2010 Nov-Dec; 54(6): 535–540.
  2. Koenig S, Truwit JD. Ventilator associ-ated
pneumonia: diagnosis,
 treatment, and Clin
Micr Reviews 2006;19(4):637‐657.
  3. Fagon
J, Chastre J, Hance
A, Montravers
P,
Novara
A,and Gibert C.
Nosocomial
pneumonia
in
ventilatedpatients:a
cohort
studyevaluating
attributable
mortality
and
hospital
Am
J
Med
1993;94:281‐288.
  4. Rello
J,
Ollendorf
D,
Oster
G,
Vera‐Llonch
M,
Bellm
L,
Redman
RKollef
Epidemiology
andoutcomes
ofventilator‐associated
pneumonia
ina
large
US
database Chest
2002; 122: 2115‐2121.
  5. Atul Ashok Kalanuria, Wendy Zai Email author  Ventilator-associated pneumonia in the ICU Critical Care201418:208
  6. H unter JD: Ventilator associated pneumonia. BMJ 2012, 344(e3325):e3325.
  7. A fshari A, Pagani L, Harbarth S: Year in review 2011: Critical care – infection. Crit Care 2012, 16:242–247
  8. A merican Thoracic Society, Infectious Diseases 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, 171:388–416.
  9. Kollef
M,
Silver
P,
Murphy
D,
andTrovillion


The
effect
of
late‐onsetventilator‐associated
pneumonia
indetermining
patient
mortality.
Chest
 1995;
108(6):

1665‐1662.
  10. Enas Elsayed Mohamed *, Alaa El Din Ali Abd Alla ; Clinical pulmonary infection score and C-reactive protein in the prediction of early ventilator associated pneumonia : Egyptian Journal of Chest Diseases and Tuberculosis (2013) 62, 453–458
  11. Pugin, R. Auckenthaler, N. Mili, et al, Diagnosis of ventilator– associated pneumonia by bacteriologic analysis of bronchoscopic and non-bronchoscopic ‘‘blind’’ bronchoalveolarlavage fluid, Am. Rev. Respir. Dis. 149 (1991) 1121–1129.
  12. Steven M. Koenigand Jonathon D. Truwit* Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention Clin Microbiol Rev. 2006 Oct; 19(4): 637–657.
  13. American Thoracic Society, Guidelines for the management of adult with hospital acquired, ventilator – associated, and healthcare – associated pneumonia, Am. J. Respir. Crit. Care Med. 171 (2005) 388–416.
  14. N. Pham, M.J. Neff, J.M. Simmons, et al, The Clinical Pulmonary Infection Score poorly predicts pneumonia in patients with burns, J. Burn Care Res. 28 (2007) 76–79.
  15. P. Smith, B.J. Lipo worth, C-reactive protein in simple community – acquired pneumonia, Chest 107 (1995) 1028–1031.
  16. Fartoukih, B. Maitre, S. Honore, et al, Diagnosing pneumonia during mechanical ventilation: the clinical pulmonary infection score revisited, Am. J. Respir. Crit. Care Med. 168 (2003) 173–179.
  17. Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med 2002;165:867–903.
  18. Rello J, Ollendorf DA, Oster G, Montserrat V, Bellm L, Redman R, Kollef MH. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest 2002;122:2121.
  19. Cook DJ, Walter SD, Cook RJ, Griffith LE, Guyatt GH, Leasa D, Jaeschke RZ, Brun-Buisson C. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med 1998;129:440.
  20. Brochard L, Mancebo J, Wysocki M, Lofaso F, Conti G, Rauss A, Simonneau G, Benito S, Gasparetto A, Lemaire F. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 1995;333:817–822.
  21. Antonelli M, Conti G, Rocco M, Bufi M, De Blasi RA, Vivino G, Gasparetto A, Meduri GU. A comparison of noninvasive positivepressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 1998;339:429–435.
  22. Hilbert G, Gruson D, Vargas F, Valentino R, Gbikpi-Benissan G, Dupon M, Reiffers J, Cardinaud JP. Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med 2001;344:817–822.
  23. Jean Chastre, Md • Charles-Edouard Luyt, MD, PhD Ventilator-Associated Pneumonia Murray and Nadel's Textbook of Respiratory Medicine (Sixth Edition) 2016, Pages 583–592.e5
  24. Nasia Safdar MD MSc, Christopher J Crnich MD MSc, and Dennis G Maki MD The Pathogenesis of Ventilator-Associated Pneumonia: Its Relevance to Developing Effective Strategies for Prevention RESPIRATORY CARE • JUNE 2005 VOL 50 NO 6
  25. Lees AW, McNaught W. Bacteriology of lower-respiratory-tract secretions, sputum, and upper-respiratory-tract secretions in “normals” and chronic bronchitics. Lancet 1959;2:1112–1115.
  26. Laurenzi GA, Potter RT, Kass EH. Bacteriologic flora of the lower respiratory tract. N Engl J Med 1961;265:1273–1278
  27. Salathe M, Wanner A. Nospecific host defenses: mucociliary clearance and cough. In: Niederman M, ed. Respiratory Infections. Philadelphia: Saunders; 1994:17–32.
  28. Zeiher BG, Hornick DB. Pathogenesis of respiratory infections and host defenses. Curr Opin Pulm Med 1996;2(3):166–173.
  29. Strieter RM, Belperio JA, Keane MP. Host innate defenses in the lung: the role of cytokines. Curr Opin Infect Dis 2003;16(3):193– 198.
  30. Klainer AS, Turndorf H, Wu WH, Maewal H, Allender P. Surface alterations due to endotracheal intubation. Am J Med 1975;58(5): 674–683.
  31. Cooper JD, Grillo HC. Experimental production and prevention of injury due to cuffed tracheal tubes. Surg Gynecol Obstet 1969; 129(6):1235–1241.
  32. Levine SA, Niederman MS. The impact of tracheal intubation on host defenses and risks for nosocomial pneumonia. Clin Chest Med 1991;12(3):523–543.
  33. Bone DK, Davis JL, Zuidema GD, Cameron JL. Aspiration pneumonia. Prevention of aspiration in patients with tracheostomies. Ann Thoracic Surg 1974;18(1):30–37.
  34. Safdar N, Maki DG. The commonality of risk factors for nosocomial colonization and infection with antimicrobial-resistant Staphylococcus aureus, enterococcus, Gram-negative bacilli, Clostridium difficile and Candida. AnnIntern Med2002;136(11): 834–844.
  35. de la Torre FJ, Pont T, Ferrer A, Rossello J, Palomar M, Planas M. Pattern of tracheal colonization during mechanical ventilation. Am J Respir Crit Care Med 1995;152(3):1028–1033.
  36. Ewig S, Torres A, El-Ebiary M, Fabregas N, Hernandez C, Gonzalez J, et al. Bacterial colonization patterns in mechanically ventilated patients with traumatic and medical head injury. Incidence, risk factors, and association with ventilator-associated pneumonia. Am J Respir Crit Care Med 1999;159(1):188–198.
  37. George DL, Falk PS, Wunderink RG, Leeper KV Jr, Meduri GU, Steere EL, et al. Epidemiology of ventilator-acquired pneumonia based on protected bronchoscopic sampling. Am J Respir Crit Care Med 1998;158(6):1839–1847.
  38. Estes RJ, Meduri GU. The pathogenesis of ventilator-associated pneumonia: I. Mechanisms of bacterial transcolonization and airway inoculation. Intensive Care Med 1995;21(4):365–383.
  39. Hamill RJ, Houston ED, Georghiou PR, Wright CE, Koza MA, Cadle RM, et al. An outbreak of Burkholderia (formerly Pseudomonas) cepacia respiratory tract colonization and infection associated with nebulizedalbuterol therapy. AnnIntern Med 1995;122(10): 762–766.
  40. Alcon A, Fabregas N, Torres A. Hospital-acquired pneumonia: etiologic considera-tions. Infect Dis Clin North Am 2003;17 (4):679– 695.
  41. Maki DG. Preventing infection in intravenous therapy. Anesth Analg 1977;56(1):141–153.
  42. Crnich CJ, Maki DG. The promise of novel technology for the prevention of intravascular device-related bloodstream infection. II. Long-term devices. Clin Infect Dis 2002;34(10):1362–1368.
  43. Takigawa K,Fujita J,Negayama K, Yamagishi Y,YamajiY,Ouchi K, et al. Nosocomial outbreak of Pseudomonas cepacia respiratory infection in immunocompromised patients associated with contaminated nebulizer devices. Kansenshogaku Zasshi1993;67(11):1115– 1125.
  44. Srinivasan A, Wolfenden LL, Song X, Mackie K, Hartsell TL, Jones HD, et al. An outbreak of Pseudomonas aeruginosa infections associated with flexible bronchoscopes. N Engl J Med 2003; 348(3):221–227.
  45. Drinka PJ, Gravenstein S, Krause P, Langer EH, Barthels L, Dissing M, et al. Non-influenza respiratory viruses may overlap and obscure influenza activity. J Am Geriatr Soc 1999;47(9):1087– 1093.
  46. Drinka PJ, Gravenstein S, Krause P, Schilling M, Miller BA, Shult P. Outbreaks of influenza A and B in a highly immunized nursing home population. J Fam Pract 1997;45(6):509–514.
  47. Drinka PJ, Gravenstein S, Schilling M, Krause P, Miller BA, Shult P. Duration of antiviral prophylaxis during nursing home outbreaks of influenza A: a comparison of 2 protocols. Arch Intern Med 1998;158 (19):2155–2159.
  48. Drinka PJ, Krause P, Schilling M, Miller BA, Shult P, Gravenstein S. Report of an outbreak: nursing home architecture and influenza-A attack rates. J Am Geriatr Soc 1996;44(8):910–913.
  49. Gravenstein S, Ambrozaitis A, Schilling M, Radzisauskiene D, Krause P, Drinka P, et al. Surveillance for respiratory illness in long-term care settings: detection of illness using a prospective research technique. J Am Med Dir Assoc 2000;1(3):122–128.
  50. Schilling M, Gravenstein S, Drinka P, Cox N, Krause P, Povinelli L, Shult P. Emergence and transmission of amantadine-resistant influenza A in a nursing home. J Am Geriatr Soc 2004;52(12): 2069–2073.
  51. Schilling M, Povinelli L, Krause P, Gravenstein M, Ambrozaitis A, Jones HH, et al. Efficacy of zanamivir for chemo-prophylaxis of nursing home influenza outbreaks.Vaccine1998;16(18):1771–1774.
  52. Meduri GU, Estes RJ. The pathogenesis of ventilator-associated pneumonia: II. The lower respiratory tract. Intensive Care Med 1995;21(5):452–461.
  53. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R, Healthcare Infection Control Practices Advisory Committee, Centers for Disease Control and Prevention. Guidelines for preventing health-care–associated pneumonia, 2003: recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004;53(RR-3):1–36
  54. Craven DE, Kunches LM, Kilinsky V, Lichtenberg DA, Make BJ, McCabe WR. Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation. Am Rev Respir Dis 1986; 133:792–796.

Corresponding Author

Dr Basanth Kumar S

Associate Professor, Dept of General Medicine

KIMS Hospital Bengaluru, India