Reducing Ventilator-Associated Trachea Bronchitis

Introduction: Incubated, mechanically ventilated patients are at increased risk for tracheobronchial colonization with a wide spectrum of bacterial pathogens that may progress to Ventilator-Associated Respiratory Infections (VARI) manifest as Ventilator-Associated Trachea Bronchitis (VAT) or Ventilator-Associated Pneumonia (VAP). Previous studies report 10% to 30% of patients with VAT can progress to VAP, resulting in increased patient morbidity and mortality, as well as significant acute and chronic healthcare costs that range from $20,000 to $40,000 per patient. In “Thinking outside the box” we emphasized use of serial lung surveillance cultures to identify and pre-emptively treat specific lung pathogens with appropriate antibiotics to reduce VAT, VAP, ventilator days, and length of Intensive Care Unit (ICU) stay, healthcare costs, patient morbidity and mortality. Methods: We previously studied significant bacterial lung colonization in 100consecutive ICU patients ventilated>48 hours with serial Semi-Quantitative Endo Tracheal Aspirates (SQ-ETA) with a positive endo tracheal Gram-stain with bacteria, polymorphonuclear leukocytes and lung culture having > ++/+++ (moderate) growth of a pathogen. We identified 34 patients with VAT and 34patients with VAP. However, 7 (21%) of the 34 VAT patients later progressed to VAP. Both VAT and VAP patients had significantly increased ventilator days (p<.001) and longer ICU stays (p<.001). Of note are the recent data by Stulik et al. emphasizing the low efficacy of vancomycin and oxacillin therapy for VAT and VAP due to Staphylococcus aureus. Conclusions: Serial surveillance cultures can help identify specific bacterial pathogens, use earlier appropriate antibiotic therapy for ventilated patients with significant lung bacterial colonization, VAT, or VAP that can improve patient outcomes and reduce healthcare costs. Both Quantitative Endo Tracheal Lung Aspirates (Q-ETA) or Semi-Quantitative (SQ-ETA) in can be cultured and treated. Aerosolized and/or intravenous antibiotic therapy can be used to treat Multi-Drug Resistant (MDR) pathogens. Data support early, appropriate antibiotic therapy to improve patient outcomes, reduce lung bacterial burden and healthcare costs. Donald E Craven1,5*, Jana Hudcova2,5, Yuxiu Lei3, Kathleen A Craven4, Syed Zaidi2 1Center for Infectious Diseases Research & Prevention, Lahey Hospital & Medical Center, Burlington, Massachusetts, USA 2 Department of Surgical Critical Care, Lahey Hospital & Medical Center, Burlington, Massachusetts, USA 3Department of Pulmonary & Critical Care Medicine, Lahey Hospital & Medical Center, Burlington, Massachusetts, USA 4Infection Control Practitioner &Epidemiologist, Wellesley, Massachusetts, USA 5Tufts University School of Medicine, Boston, Massachusetts, USA *Corresponding author: Donald E Craven, Infectious Diseases Research & Prevention, Lahey Hospital & Medical Center, 41 Mall Rd., Burlington, MA 01805, USA. Tel: + 16178751128; Email: donald.e.craven@lahey.org; donald.e.craven@gmail.com Citation: Craven DE, Hudcova J, Lei Y, Craven KA, Zaidi S (2017) Reducing Ventilator-Associated Trachea Bronchitis & Pneumonia: Lung Surveillance Cultures & Pre-Emptive Therapy Improve Outcomes. Infect Dis Diag Treat: IDDT-110. Received Date: 4 July, 2017; Accepted Date: 25 September, 2017; Published Date: 2 October 5, 2017 Citation: Craven DE, Hudcova J, Lei Y, Craven KA, Zaidi S (2017) Reducing Ventilator-Associated Trachea Bronchitis & Pneumonia: Lung Surveillance Cultures & Pre-Emptive Therapy Improve Outcomes. Infect Dis Diag Treat: IDDT-110. 2 Volume 2017; Issue 02 Introduction Recent data suggest that Ventilator-Associated Respiratory Infections (VARI) may begin with tracheal colonization that can multiply and progress to Ventilator-Associated Tracheobronchitis (VAT) or Ventilator-Associated Pneumonia (VAP), as shown in Figures1-2 [1-12]. Figure 1: Schematic of an incubated intensive care unit (ICU) patient with an Endo Tracheal Tube (ETT), or Oro Gastric Tube (OGT) with high concentrations of bacteria in sub glottis secretions that collect above the ETT cuff, which can leak around the cuff into the lung. Also, bacteria-encased biofilm develops in the ETT lumen over time that can be embolized into the trachea bronchial tree and lung parenchyma with ETT suctioning or bronchoscopy causing significant tracheal colonization, Ventilator-Associated Tracheobronchitis (VAT) and/or pneumonia (VAP). Heavy endo tracheal colonization, VAT and VAP are defined by Quantitative-Endo Tracheal Aspirates (Q-ETA) >10 [3-5] colony forming units (cfu)/ml or Semi-Quantitative-ETA (SQ-ETA) aspirates having > ++/+++ growth of a pathogen on agar plates. Gram-stained ETAs are examined for polymorph nuclear leukocytes and/or presence of bacteria/high power field that is consistent with a diagnosis of bacterial colonization, VAT or VAP Figure 2: Schematic of the extensive the left tracheobronchial tree surrounded by thousands air-filled alveoli shown in insert (B) using electron microscopy of air filled lung tissue. In VAP insert A, allows entering right lung bacteria causing significant airway colonization, Ventilator-Associated Tracheobronchitis (VAT) or pneumonia (VAP) shown in insert (A) with bacterial pathogens that enter the lower respiratory tract from the or pharynx or by leakage of bacteria or lung secretions around the Endo Tracheal Tube (ETT) tube cuff, or biofilm-encased bacteria forming in the ETT lumen. Note numerous polymorph nuclear macrophages or polymorph nuclear leukocytes in VAP Part A. Lung bacterial burden can be reduced by early appropriate intravenous and/or aerosolized antibiotics to reduce lung colonization, VAT and/or VAP. Adapted in part from: Craven DE, et al. “Antibiotic Treatment of Ventilator-Associated Tracheobronchitis”. We previously studied significant lung colonization in 100 out of 234 consecutive incubated patients ventilated >48 hours that had many different bacterial pathogens shown in Table 1 and Figure 3. There were 39ventilated patient’s with heavy bacterial colonization, and 61 patient shad VARI, which included 34 patients with VAT and 34 with VAP [12]. However, 7 (21%) of the 34 patients initially diagnosed with VAT subsequently developed VAP. Bacterial Pathogens Antibiotic Therapy Gram-Negative Bacilli Pseudomonas aeruginosa ,Escherichia coli Anti-pseudomonal cephalosporin e.g., cefepime, ceftazidime