[醫學筆記] 2016 IDSA HAP/VAP guideline 院內肺炎/呼吸器相關肺炎 治療指引

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臨床在顧，該賴要讀 ; 臨床在走，該賴要有。

2016年IDSA和ATS睽違十多年推出了全新改版HAP(hospital-acquired pneumonia)/VAP(Ventilator-acquired pneumonia)臨床診斷治療指引。

2017年歐洲也不甘示弱？推出新版該賴，因為小弟被分派到要在咪挺上報(24頁眼神死)，所以就來兩版超級比一比同行對不起。

現在該賴都流行你問我答Q&A的模式，美國版回答了25個子題，歐洲版則是回答了七大項的問題

來來來，全文免錢下載底加：

美國該賴：

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

歐洲該賴：

International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia

那麼先來一個懶人包比較

 ERS/ESICM/ESCMID/ALAT IDSA/ATS
Microbiological
For suspected VAP
- obtaining distal quantitative samples to reduce antibiotic exposure
- obtaining a lower respiratory tract sample (distal quantitative or proximal quantitative or qualitative culture) to focus and narrow the initial empiric antibiotic therapy
For suspected VAP
- Abx be withheld for negative invasive quantitative culture results
- noninvasive sampling with semiquantitative cultures to diagnose VAP

Fot suspected HAP (non-VAP)
- Microbiologic-guided treatment according to noninvasive samples
TreatmentEmpiric treatment for VAP/HAP
- SA, PsA, and other GNB coverage for all pts
MRSA coverage?
- if any risk factor for abx resistance
- if >10-20% SA isolates are resistant
- if the prevalence of MRSA is not known
- HAP:ventilator support or septic shock
Dual anti-PsA ?
- if any risk factor for abx resistance
- >10% GNB isolates are resistant
- if the susceptibility rates are not available
- structural lung disease
- HAP:ventilator support or septic shock
DurationA 7-8 day courseA 7-day course
Biomarkers/
clinical score
- perfroming routine biomarkers for outcome/clinical response at 72-96 h is not recommended
- serial PCT measurement to reduce the duration is not recommended if the anticipated duration is 7-8 days
- Using clinical criteria alone to decide initiation of abx (PCT,sTREM1,CRP,CPIS not suggested)
- Using PCT + clinical criteria to guide the discontinuation
- Not using CPIS to guide the discontinuation
SOD/SDD- not to issue a recommendation on the use of chlorhexidine to perform SOD due to the unclear balance between a potential reduction in pneumonia rate and a potential increase in mortality
- SOD, but not SDD, in settings with low rates of antibiotic-resistant bacteria and low antibiotic consumption
not discussed

然後來一個自製流程

這是歐洲的治療流程

這是美國的懶人包大全

 

可以參考陳偉挺醫師的BLOG，寫得相當明明白白我的心：

2016 IDSA HAP / VAP guidelines update：加強風險評估的治療策略

這版改變的內容以及強調的重點如下

  1. HCAP (Health-care associated pneumonia) 掰掰大步地走開。

之前特別強調具某些危險因子的族群，是因為認為這群病人可能因時常出入醫療院所，而有較高機率得到抗藥性菌株感染。但後來的研究並不支持這樣的假設，反而認為病人的underlying characteristics才和感染抗藥性菌株的風險有關，所以這次IDSA揮淚(應該沒有)斬HCAP。那讓我們再看一眼之前HCAP的內容然後剪碎了讓它隨風吹向大海

  • Presence of risk factors for HCAP: Hospitalization for 2 d or more in the preceding 90 d
  • Residence in a nursing home or extended care facility
  • Home infusion therapy (including antibiotics)
  • Chronic dialysis within 30 d
  • Home wound care
  • Family member with multidrug-resistant pathogen

其實該賴有說這群病人之後何去何從請靜待下一版CAP該賴分曉。我覺得有點困惑那原本這群病人的診斷是變成CAP嗎?臨床上感覺老師們還是會用Anti-PsA的抗生素…

2. Local antibiogram data 在地的卡實在

各家醫院感控都會做院內的抗藥性菌譜，比如說敝院就盛產….(痾還是不要亂說好了以免被查XD)

3. Short-course is recommended 長一點久一點不如夠用就好(咦？)，想要用久一點要看條件(持續歪)

好的以下還是逐條審查看一下這篇落落長的該賴到底在說什麼

= Introduction =

HAP 約佔院內感染22%。

VAP 約佔所有呼吸器病人10%且比例在過去十年來並未下降。

VAP 的病人all-cause mortality在不同研究之間有所差異(20~50%)，有研究估計單就VAP造成的死亡約13%。

Risk facotors

恩，這張圖就講完了啊。

有些研究顯示 MRSA colonization 和從呼吸道培養出MRSA isolation有正相關，但也有研究並無法證實這樣的關聯性。目前尚未有足夠研究支持是否該用MRSA screening作為治療上的指引。

= MICROBIOLOGIC METHODS TO DIAGNOSE =
  • Noninvasive sampling with semiquantative cultures to diagnose VAP
  • Antibiotics should be withheld for patients whose culture results obtained invasively are below the diagnostic threshold (PSB < 103 CFU/mL, BAL < 104/mL)

診斷只需要用Noninvasive且semiquantitative的採檢即可，但如果已經用bronchoscopy留到invasive sampling，那麼可以根據這個檢體作為停用抗生素的依據。

= Biomarkers and clinical score to diagnose =

診斷HAP/VAP並決定要不要上Abx只要Clinical criteria alone, alone, alone. 很想點播一首Alone(不要問我哪個年代)再配上一張Forever alone meme圖。

Procalcitonin?免。sTREM-1?免。CRP?免。CPIS?免。

= Initial treatment of VAP and HAP =

好了要來進入治療了，首先該賴再次強調local antibiogram，所以請記得查一下貴院的感受性報表。

= VAP =

針對所有懷疑VAP的起手式該賴建議所選的Abx都要能打中MSSA, PsA, 跟其他GNB。在選用empiric abx的時候要考慮兩點：1. 要不要打MRSA 2. 要不要用兩種anti-PsA

Anti-MRSA? 

  • Patients with a risk factor of abx resistance （請查上面的表格）
  • Units where the prevalence of MRSA is > 10-20%
  • Units where the prevalence of MRSA is not known

而建議對付MRSA的Abx是vancomycin或linezolid.

而不符合以上三點的話就選擇可以打MSSA的abx即可，該賴建議以下幾種: piperaillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. (那個別忘了ceftazidime打不到MSSA所以起手式請別開雖然我之前常看到這種讓我黃人問號的打法)

不過如果是proven MSSA, 請選用oxacillin或cefazolin(恩本島應該沒有naficillin..)

2 Anti-PsA??

符合以下這些其中一項起手式請選用兩種anti-PsA

  • Patients with a risk factor of abx resistance （請查上面的表格）
  • Units where  > 10% of GN isolates are resistant to the abx considered 
  • Units where the local antibiogram is not known
  • Patients with structural lung disease (ie, bronchiectasis or cystic fibrosis)

而抗生素的選擇還有這些建議：

  • 選擇兩種不同類別的anti-PsA(也就是一個β-lactam類加一個non β-lactam類的意思)。
  • Aminoglycosides跟colistin能不用則不用

= HAP =

其實HAP跟VAP選用抗生素的思路差不多，就是加入了個high risk of mortality作為考量，而high risk 裡面仔細一看也就是need of ventilatory support跟septic shock。

好我還是乖巧溫順的列出來給大家看一下

Anti-MRSA? 

  • Patients with a risk factor of abx resistance （請查上面的表格）
  • Units where the prevalence of MRSA is > 10-20%
  • Units where the prevalence of MRSA is not known
  • Patients at high risk of mortality (need of ventilatory support or septic shock )

建議的抗生素是vancomycin或linezolid

2 Anti-PsA??

符合以下這些其中一項起手式請選用兩種anti-PsA

  • Patients with a risk factor of abx resistance （請查上面的表格）
  • Patients at high risk of mortality (need of ventilatory support or septic shock )
  • Patients with structural lung disease (ie, bronchiectasis or cystic fibrosis)

這部分倒是沒有提resistant GNB的比例多少要考慮用兩種。

而抗生素的選擇該賴上是寫”avoid 2 β-lactams” ，我想就一樣是β跟non-β各選一種組合吧。

= PK/PD optimization =

該賴建議abx的劑量應該依據PK/PD調整，而非死守廠商提供的建議劑量。

= Inhaled therapy =

如果VAP的病人分離出的菌株為僅對aminoglycoside或polymyxin類有效的GNB，該賴建議除了intravenous abx外，應該同時加上inhaled abx

該賴也提到IH abx可以做為last reosrt，也就是當治療上對單用iv abx反應不佳時，儘管菌株非MDR pathogen，無招可出的情況下還是可以試試看加上IH abx

= Pathogen-specific therapy =

PathogensAbx of choice
MRSAvancomycin
linezolid
PsA- based on susceptibility
- avoid AG monotherapy
- 2 anti-PsA for mortality risk> 25% and persistent septic shock even if susceptibility is known
ESBL GNBbased on susceptibility
Actinobacter species- carbapenem or ampicillin/sulbactam if S
- IV + IH polymyxin if pathogen only S to polymyxins
- Against the use of tigecycline
Carbapenem-resistantIV+IH polymyxins if pathogen only S to polymyxins

= Length of therapy =

七天！七天！七天就夠了但當然要看臨床反應而定，可以延長抗生素治療時間。

= De-escalastion =

能降則降。

= Discontinuation =

Procalcitonin被建議用於評估是否停止抗生素治療。

CPIS則不被建議用於協助判斷是否停藥(哭哭診斷跟停藥都沒角色)。

以上是整理美版的指引建議，臨床在走雖然該賴要有，但我想你知道每個病人的治療都應該依據病情個別化考量，死守該賴並非最佳選擇。

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