Nozokomiyal Pnömoni
Özet
Nozokomiyal pnömoni (NP), yüksek morbidite ve mortalite oranlarıyla sağlık sistemlerine ciddi mali yük getiren, hastaneye yatıştan en az 48 saat sonra gelişen yaygın bir enfeksiyondur. Non-entübe hastalarda hastane kökenli (HKP), mekanik ventilasyondaki hastalarda ise ventilatörle ilişkili pnömoni (VİP) olarak ikiye ayrılır. Tanı klinik bulgular, pürülan balgam ve laboratuvar testlerinin yanı sıra akciğer grafisi, bilgisayarlı tomografi ve son dönemde popülerleşen yüksek doğruluk oranına sahip akciğer ultrasonu ile konur; kesin etken tespiti için alt solunum yolu kültürleri altın standarttır. Ampirik antibiyotik tedavisinin seçiminde hastanın hastanede kalış süresi, yerel epidemiyoloji ve çoklu ilaç direnci (ÇİD) risk faktörleri esas alınır; en sık izole edilen patojenler Pseudomonas aeruginosa, Acinetobacter spp. ve Staphylococcus aureus gibi dirençli ajanlardır. Tedavinin takibinde prokalsitonin gibi biyobelirteçlerden yararlanılır ve komplikasyonları azaltmak amacıyla antibiyotik kullanımı genellikle 7-10 günle sınırlandırılır. Korunmada ise düzenli ağız bakımı, yatak başının yükseltilmesi, el hijyeni ve zamanında aşılama gibi aspirasyon ile hastane içi bulaşı önleyici stratejiler kritik öneme sahiptir.
Nosocomial pneumonia (NP) is a common infection developing at least 48 hours after hospital admission, imposing a significant financial burden on healthcare systems due to its high morbidity and mortality rates. It is classified into hospital-acquired pneumonia (HAP) in non-intubated patients and ventilator-associated pneumonia (VAP) in mechanically ventilated patients. Diagnosis relies on clinical findings, purulent sputum, and laboratory tests, supported by chest radiography, computed tomography, and recently advancing lung ultrasound with high accuracy, while lower respiratory tract cultures remain the gold standard for pathogen isolation. The selection of empirical antibiotic therapy is guided by the duration of hospitalization, local epidemiology, and multi-drug resistance (MDR) risk factors; the most frequently isolated pathogens include resistant agents such as Pseudomonas aeruginosa, Acinetobacter spp., and Staphylococcus aureus. Biomarkers like procalcitonin assist in monitoring, and antibiotic therapy is generally limited to 7-10 days to minimize complications. Prevention critically depends on strategies aimed at reducing aspiration and in-hospital transmission, including regular oral care, elevating the head of the bed, hand hygiene, and timely vaccination.
Referanslar
Koulenti D, Tsigou E, Rello J. Nosocomial pneumonia in 27 ICUs in Europe: perspectives from the EU-VAP/CAP study. European Journal of Clinical Microbiology & Infectious Diseases; 2017; 36(11): 1999–2006. doi: 10.1007/s10096-016-2703-z.
Kalil A, Metersky M, Klompas M, et al. Management of adults with hospitalacquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clinical Infectious Diseases;2016; 63(5): e61–e111. doi: 10.1093/cid/ciw353.
Papazian L, Klompas M, Luyt CE. Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Medicine;2020; 46(5):888–906. doi: 10.1007/s00134-020-05980-0.
Leone M, Bouadma L, Bouhemad B, et al. Brief summary of French guidelines for the prevention, diagnosis and treatment of hospital-acquired pneumonia in ICU. Annals of Intensive Care; 2018; 8(1): 104. doi: 10.1186/s13613-018-0444-0.
Torres A, Niederman MS, Chastre J, et al. International ERS/ESICM/ESCMID/ ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia. European Respiratory Journal; 2017; 50(3): 1700582. doi: 10.1183/13993003.00582-2017.
Ferreira-Coimbra J, Ardanuy C, Diaz E, et al. Ventilator-associated pneumonia diagnosis: a prioritization exercise based on multicriteria decision analysis. European Journal of Clinical Microbiology & Infectious Diseases;2020; 39(2): 281–286. doi: 10.1007/s10096-019-03720-x.
Fernando SM, Tran A, Cheng W, et al. Diagnosis of ventilator-associated pneumonia in critically ill adult patients – a systematic review and metaanalysis. Intensive Care Medicine; 2020; 46(6): 1170–1179. doi: 10.1007/s00134-020-06036-z.
Winkler MH, Touw HR, van de Ven PM, et al. Diagnostic accuracy of chest radiograph, and when concomitantly studied lung ultrasound, in critically ill patients with respiratory symptoms: a systematic review and meta-analysis. Critical Care Medicine; 2018; 46(7): e707–e714. doi: 10.1097/CCM.0000000000003129.
Hoesein FM. Low-dose computed tomography instead of radiography in suspected pneumonia. Breathe ;2019; 15(1): 81–83. doi: 10.1183/20734735.0319-2018.
Koulenti D, Zhang Y, Fragkou PC. Nosocomial pneumonia diagnosis revisited. Current Opinion in Critical Care;2020; 26(5): 442–449. doi:10.1097/mcc.0000000000000756.
Bouhemad B, Dransart-Raye´ O, Mojoli F, et al. Lung ultrasound for diagnosis and monitoring of ventilator-associated pneumonia. Annals of Translational Medicine; 2018; 6(21): 418. doi: 10.21037/atm.2018.10.46.
Staub LJ, Biscaro RRM, Maurici R. Emergence of alveolar consolidations in serial lung ultrasound and diagnosis of ventilator-associated pneumonia. Journal of Intensive Care Medicine; 2021; 36(3): 304-312. doi: 10.1177/0885066619894279.
Staub LJ, Biscaro RRM, Maurici R. Accuracy and applications of lung ultrasound to diagnose ventilator-associated pneumonia: a systematic review. Journal of Intensive Care Medicine;2018; 33(8): 447–455. doi: 10.1177/0885066617737756.
Xia Y, Ying Y, Wang S, et al. Effectiveness of lung ultrasonography for diagnosis of pneumonia in adults: a systematic review and meta-analysis. Journal of Thoracic Disease;2016; 8(10): 2822–2831. doi: 10.21037/jtd.2016.09.38.
Zagli G, Cozzolino M, Terreni A, et al. Diagnosis of ventilator-associated pneumonia: a pilot, exploratory analysis of a new score based on procalcitonin and chest echography. Chest; 2014;146(6): 1578–1585. doi: 10.1378/chest.13-2922.
Zhou J, Song J, Gong S, et al. Lung ultrasound combined with procalcitonin for a diagnosis of ventilator-associated pneumonia. Respiratory Care; 2019; 64: 519–527. doi: 10.4187/respcare.06377.
Feinsilver SH, Fein AM, Niederman MS, et al. Utility of fiberoptic bronchoscopy in nonresolving pneumonia. Chest; 1990; 98(6): 1322–1326. doi:10.1378/chest.98.6.1322.
Balthazar AB, Von Nowakonski A, De Capitani EM, et al. Diagnostic investigation of ventilator-associated pneumonia using bronchoalveolar lavage: comparative study with a postmortem lung biopsy. Brazillian Journal of Medical and Biological Research;2001; 34(8): 993–1001. doi:10.1590/s0100-879x2001000800004.
Kirtland SH, Corley DE, Winterbauer RH, et al. The diagnosis of ventilator-associated pneumonia: a comparison of histologic, microbiologic, and clinical criteria. Chest;1997; 112(2): 445–457. doi:10.1378/chest.112.2.445.
Liapikou A, Cillo´ niz C, Torres A. Emerging strategies for the noninvasive diagnosis of nosocomial pneumonia. Expert Review of Anti-infective Therapy Journal; 2019; 17: 523–533. doi: 10.1080/14787210.2019.1635010.
Parente DM, Cunha CB, Mylonakis E, Timbrook TT. The clinical utility of methicillin-resistant Staphylococcus aureus (MRSA) nasal screening to rule out MRSA pneumonia: a diagnostic meta-analysis with antimicrobial stewardship implications. Clinical Infectious Diseases;2018; 67(1): 1–7. doi:10.1093/cid/ciy024.
Hong HL, Hong SB, Ko GB, et al. Viral infection is not uncommon in adult patients with severe hospital-acquired pneumonia. PLoS One; 2014; 9(4): e95865. doi:10.1371/journal.pone.0095865.
Bartley PB, Ben Zakour NL, Stanton-Cook M, et al. Hospital-wide eradication of a nosocomial Legionella pneumophila serogroup 1 outbreak. Clinical Infectious Diseases;2016; 62: 273–279. doi: 10.1093/cid/civ870.
Liu C, Wang F, Cui L, et al. Diagnostic value of serum neutrophil gelatinase-associated lipocalin, interleukin-6 and anticitrullinated alpha-enolase peptide 1 for lower respiratory tract infections. Clinical Biochemistry; 2020; 75: 30–34. doi: 10.1016/j.clinbiochem.2019.09.008.
Ding HG, Zhou HF, Diao MY, et al. A novel biomarker of serum histidine-rich glycoprotein (HRG) for diagnosing and predicting prognosis of ventilatorassociated pneumonia (VAP): a pilot study. European Review for Medical and Pharmacological Sciences; 2018; 22: 7920–7927. doi: 10.26355/eurrev_201811_16419.
Luyt C-E, Hékimian G, Koulenti D, et al. Microbial cause of ICU-acquired pneumonia:hospital-acquired pneumonia versus ventilator-associated pneumonia. Current Opinion in Critical Care;2018;24(5): 332-338. doi:10.1097/mcc.00000000000005.
Martin-Loeches I, Rodriguez AH, Torres A. New guidelines for hospital-acquired pneumonia/ventilator-associated pneumonia:USA vs. Europe. Current Opinion in Critical Care; 2018;24(5): 347-352. doi:10.1097/mcc.0000000000000535.
Chastre J, Wolff M, Fagon J-Y, et al. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA. 2003;290(19): 2588–2598. doi: 10.1001/jama.290.19.2588.
Pugh R, Grant C, Cooke RP, et al. Short‐course versus prolonged‐course antibiotic therapy for hospital‐acquired pneumonia in critically ill adults. Cochrane Database Syst Rev [Internet] 2011. (19 Mayıs 2020 tarihinde https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007577 adresinden ulaşılmıştır).
Dimopoulos G, Poulakou G, Pneumatikos IA, et al. Short- vs long-duration antibiotic regimens for ventilator-associated pneumonia: a systematic review and meta-analysis. Chest; 2013;144(6): 1759–1767. doi: 10.1378/chest.13-0076.
Torres A, Barberán J, Ceccato A, et al. Hospital-Acquired Pneumonia. Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) Guidelines. 2019 Update. Archivos de Bronconeumologia; 2020;56(1): 11–19.
Modi AR, Kovacs CS. Hospital-acquired and ventilator-associated pneumonia: Diagnosis, management, and prevention. Cleveland Clinic Journal of Medicine; 2020;87(10): 633-639. doi: 10.3949/ccjm.87a.19117.
Kaneoka A, Pisegna JM, Miloro KV, et al. Prevention of healthcare-associated pneumonia with oral care in individuals without mechanical ventilation: a systematic review and meta-analysis of randomized controlled trials. Infection Control & Hospital Epidemiology; 2015; 36(8): 899–906. doi:10.1017/ice.2015.77.
Lansford T, Moncure M, Carlton E, et al. Efficacy of a pneumonia prevention protocol in the reduction of ventilator-associated pneumonia in trauma patients. Surgical Infections (Larchmt);2007; 8(5): 505–510. doi:10.1089/sur.2006.001.
Xie X, Lyu J, Hussain T, Li M. Drug prevention and control of ventilator-associated pneumonia. Frontiers in Pharmacology; 2019; 10: 298. doi:10.3389/fphar.2019.00298.
Leone M, Bouadma L, Bouhemad B, et al. Hospital-acquired pneumonia in ICU. Anaesthesia Critical Care & Pain Medicine; 2018; 37(1): 83–98. doi:10.1016/j.accpm.2017.11.006.
Lyons PG, Kollef MH. Prevention of hospital-acquired pneumonia. Current Opinion in Critical Care; 2018;24(5): 370–378. doi:10.1097/MCC.0000000000000523.
