Brief summary of French guidelines for the prevention, diagnosis and treatment of hospital-acquired pneumonia in ICU

(2018) 8:104 Leone et al. Ann. Intensive Care https://doi.org/10.1186/s13613-018-0444-0 Open Access RESEARCH Brief summary of French guidelines for the prevention, diagnosis and treatment of hospital‑acquired pneumonia in ICU Marc Leone1*, Lila Bouadma2, Bélaïd Bouhemad3, Olivier Brissaud4, Stéphane Dauger5, Sébastien Gibot6, Sami Hraiech7, Boris Jung8, Eric Kipnis9, Yoann Launey10, Charles‑Edouard Luyt11, Dimitri Margetis12, Fabrice Michel13, Djamel Mokart14, Philippe Montravers15, Antoine Monsel16, Saad Nseir17, Jérôme Pugin18, Antoine Roquilly19, Lionel Velly20, Jean‑Ralph Zahar21, Rémi Bruyère22, Gérald Chanques23, ADARPEF and GFRUP Abstract Background: The French Society of Anaesthesia and Intensive Care Medicine and the French Society of Intensive Care edited guidelines focused on hospital-acquired pneumonia (HAP) in intensive care unit. The goal of 16 Frenchspeaking experts was to produce a framework enabling an easier decision-making process for intensivists. Results: The guidelines were related to 3 specific areas related to HAP (prevention, diagnosis and treatment) in 4 identified patient populations (COPD, neutropenia, post-operative and paediatric). The literature analysis and the for‑ mulation of the guidelines were conducted according to the Grade of Recommendation Assessment, Development and Evaluation methodology. An extensive literature research over the last 10 years was conducted based on publica‑ tions indexed in PubMed™ and Cochrane™ databases. Conclusions: HAP should be prevented by a standardised multimodal approach and the use of selective digestive decontamination in units where multidrug-resistant bacteria prevalence was below 20%. Diagnosis relies on clinical assessment and microbiological findings. Monotherapy, in the absence of risk factors for multidrug-resistant bacteria, non-fermenting Gram-negative bacilli and/or increased mortality (septic shock, organ failure), is strongly recom‑ mended. After microbiological documentation, it is recommended to reduce the spectrum and to prefer monother‑ apy for the antibiotic therapy of HAP, including for non-fermenting Gram-negative bacilli. Introduction Hospital-acquired pneumonia (HAP) is the most common infection in the intensive care unit (ICU) [1]. In the ICU, HAP is associated with a mortality rate of 20% and with increased duration of mechanical ventilation and ICU and hospital length-of-stay [2, 3]. The criteria to diagnose pneumonia are shown in Table 1 (Fig. 1). *Correspondence: Marc.LEONE@ap‑hm.fr 1 Service d’Anesthésie et de Réanimation, Aix-Marseille Universite Hopital Nord, chemin des Bourrely, 13015 Marseille, France Full list of author information is available at the end of the article Method Sixteen French-speaking experts produce guidelines in three specific areas related to HAP: prevention, diagnosis and treatment as well as the specificities pertaining to different identified patient populations (COPD, neutropenia, post-operative and paediatric). The schedule of the group was defined upstream (Table 2) (Fig. 2). The questions were formulated according to the PICO (Patient, Intervention, Comparison, Outcome) format. The formulation of the guidelines was conducted according to the GRADE methodology (Grade of Recommendation Assessment, Development and Evaluation) [4, 5]. In the absence of supporting literature, a question could be addressed by a recommendation under the form of an expert opinion (“the experts suggest that…”) (Fig. 3). © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Leone et al. Ann. Intensive Care (2018) 8:104 Page 2 of 7 Table 1 Criteria for defining pneumonia Table 2 Guideline timeline Radiological signs 5 December 2016 Start-up meeting 6 March 2017 Vote: first round 13 March 2017 Post-vote deliberation meeting 1 April 2017 Vote: second round 16 April 2017 Amendment of two guidelines 28 April 2017 Vote of the two amended guidelines 10 May 2017 Guideline finalisation meeting Two successive chest radiographs showing new or progressive lung infiltrates In the absence of medical history of underlying heart or lung disease, a single chest radiograph is enough And at least one of the following signs Body temperature > 38,3 °C without any other cause Leucocytes < 4000/mm3 or ≥ 12,000/mm3 And at least two of the following signs Purulent sputum Cough or dyspnoea Declining oxygenation or increased oxygen requirement or need for respiratory assistance These guidelines with their arguments were published in the journal Anaesthesia Critical Care and Pain Medicine [6] (Fig. 4). First area, PREVENTION Which HAP prevention approaches decrease morbidity and mortality in ICU patients? R1.1 We recommend using a standardised multimodal HAP prevention approach in order to decrease ICU patient morbidity (Grade 1+). R1.1 Paediatrics We suggest using a standardised multimodal approach aiming at preventing HAP in order to decrease paediatric ICU patient morbidity (Grade 2+). R1.2 In units where multidrug-resistant bacteria prevalence is low (< 20%), we suggest applying routine selective digestive decontamination using a topical antiseptic administered enterally and a maximal 5-day course of systemic prophylactic antibiotic to decrease mortality (Grade 2+). R1.3 Within a standardised multimodal HAP prevention approach, we suggest combining some of the following methods to decrease ICU patient morbidity: • Promote the use of non-invasive ventilation to avoid tracheal intubation (mainly in post-operative digestive surgery patients and in patients with COPD), • Favour orotracheal over nasotracheal intubation when required Protocol 1 1- Favour non-invasive venlaon (NIV) (mainly following digesve surgery and for COPD paents) When invasive venlaon is required : 2- Apply* a selecve digesve decontaminaon protocol with prophylacc systemic anbioc treatment <5 days *if the prevalence of mulresistant bacteria is low (<20%) 3- Associate some of the following methods (1st line): Favour the use of NIV to prevent intubation Limit dose and duration of sedatives and analgesics associated with mechanical ventilation Initiate early enteral feeding Regularly verify endotracheal tube cuff pressures Perform sub-glottic suction (/6-8 hours) using an appropriate endotracheal tube Favour the orotracheal route for intubation NB: The associaon of head of bed elevaon <30r and/or oro-pharyngeal decontaminaon with 0.12 or 0.2% chlorhexidine could be proposed in associaon to these measures, despite low efficiency, because they do not cost much and are well tolerated. 4- Avoid using the following methods (...truncated)