(Thai Clinical Practice Guidelines for Management and ...

1 4 ( 5 .. ) ( thai Clinical Practice Guidelines for Management and Prevention of Adults with Hospital-acquired and Ventilator-associated Pneumonia) 1. ( Clinical Practice Guidelines ) (hospital-acquired pneumonia, HAP) (ventilator-associated pneumonia, VAP) (supportive therapy) (intensive monitoring) (evidence-based)

2 (expert opinion) (quality of evidence) (strength of recommendation) (Infectious Diseases Society of America, IDSA) (United States Public Health Service) 11 2 I.

3 (hospital-acquired pneumonia, HAP) 48 1 (ventilator-associated pneumonia, VAP) 48 48 1 (healthcare-associated pneumonia, HCAP) 48 90 nursing home long-term care facility 30 (hemodialysis unit)1 (early-onset HAP or VAP) HAP VAP 48 4 1 (late-onset HAP or VAP)

4 HAP VAP 4 1 > 1 > 38 1 > 2 (endotracheal tube) (orotracheal) (nasotracheal) (tracheostomy tube)1 neutrophils> 25 /low-power field (LPF) squamous epithelial cells <10 /LPF3 (HCAP) (aspiration pneumonia) nursing home longterm care facility (immunocompetent adults) (human immunodeficiency virus, HIV) (hematologic malignancy) (neutropenia) (transplantation) (good Clinical judgement)

5 II. HAP VAP1-8 3 2 HAP VAP (etiologic pathogen) HAP VAP HAP VAP ( Clinical suspicion) (new onset) (purulent sputum) (complete blood count, CBC) (chest X-ray)

6 HAP VAP infiltrate (new) (progressive) 2 3 .. ( ) . 12,000 / (12 x 109 / ) 4,000 / (4 x 109 / )1,5,8 HAP VAP 1 3 (empirical antibiotic) (over diagnosis) 3 (under diagnosis)

7 Fabregas (gold standards) HAP VAP 69 75 5 HAP VAP sepsis 1 (pulmonary embolism)

8 Pugin 4 HAP VAP Clinical pulmonary infection score (CPIS) 4 6 HAP VAP (quantitative culture) (bronchoalveolar lavage, BAL) (bronchoscopy) 4 (gold standard) Fabregas 5 CPIS 77 42 CPIS HAP VAP CPIS (Gram staining) endotracheal aspirate (protected specimen brush, PSB)6 endotracheal aspirate (inflammatory cells) 72 HAP VAP 94 ( IIA)

9 9 Singh 7 modified CPIS ( 26) HAP VAP 5 6 3 7 1 3 6 3 10-21 HAP VAP 3 6

10 ( IA) HAP VAP infiltrate 2 3 .. 12,000 / 4,000 / HAP VAP endotracheal aspirate 72 HAP VAP infiltration modified CPIS Singh empirical 3 6 5 ( 1)