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Management of pneumonia in the ICU
1 Plays9 months ago
In this episode, Dr. Sergio Zanotti discusses the different aspects of managing pneumonia in critically ill patients. He covers the initial management of severe pneumonia, management of ventilator-associated pneumonia, and highlights the clinical approach to non-resolving pneumonia in the intensive care unit (ICU). He is joined by Dr. Andre Kalil, a physician specializing in critical care and infectious diseases. Dr. Kalil is a Professor in the Division of Infectious Diseases and Director of Transplant Infectious Diseases at the University of Nebraska Medical Center (UNMC).
Additional resources:
How to approach a patient hospitalized for pneumonia who is not responding to treatment? Pedro Povoa, et al. Intensive Care Med 2025: https://link.springer.com/article/10.1007/s00134-025-07903-3
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. Andre Kalil, et al. Clin Infect Dis. 2016: https://pmc.ncbi.nlm.nih.gov/articles/PMC4981759/
Management of Ventilator-Associated Pneumonia: Guidelines. M Metersky and Andre c. Kalil. Infect Dis Clin North Am. 202: https://pubmed.ncbi.nlm.nih.gov/38280768/
Hydrocortisone in Severe Community-Acquired Pneumonia. CAPE-COD Clinical Trial. N Eng J of Med 202: https://www.nejm.org/doi/full/10.1056/NEJMoa2215145
Continuous vs. Intermittent β-Lactam Antibiotic Infusions in Critically Ill Patients with Sepsis. BLING III Clinical Trial. JAMA 2024: https://jamanetwork.com/journals/jama/fullarticle/2819971
Music mentioned in this episode:
Pat Metheny Group – We Live Here: https://bit.ly/44gt8Jl
Antonio Carlos Jobin – Terra Basilis: http://bit.ly/4k4Amq1
Mahler: Symphony No.9 – Chicago Symphony Orchestra: http://bit.ly/4k9sXWn
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Transcript
Introduction and Overview
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
Managing Pneumonia in ICU Patients
00:00:33
Speaker
Pneumonia is a common diagnosis in the ICU.
00:00:36
Speaker
In today's podcast, we will discuss different aspects of managing pneumonia in critically ill patients.
00:00:41
Speaker
We will cover the initial management of severe pneumonia, discuss management of ventilator-associated pneumonia, and then cover the clinical approach to non-resolving pneumonia in the intensive care unit.
00:00:53
Speaker
Our guest is Dr. Andre Khalil, a physician specializing in critical care and infectious disease.
00:00:58
Speaker
Dr. Khalil is a professor in the Division of Infectious Disease and director of transplant infectious diseases at the University of Nebraska Medical Center.
00:01:07
Speaker
A renowned clinician, educator, and researcher, Dr. Khalil has received numerous distinctions, including the 2021 Scientist Laureate Award at the University of Nebraska Medical Center.
00:01:17
Speaker
Dr. Khalil is a prolific author and has participated in several IDSA and SECM clinical guidelines and has written extensively on the topic of hospital and ventilator-associated pneumonias.
00:01:30
Speaker
His most recent paper is entitled, How to Approach a Patient Hospitalized for Pneumonia Who is Not Responding to Treatment.
00:01:38
Speaker
André, welcome back to Critical Matters.
00:01:41
Speaker
Thanks so much, Sergio.
00:01:42
Speaker
I mean, it's really a true pleasure to be here back with you.
00:01:45
Speaker
And thanks so much for the invitation.
00:01:47
Speaker
I'm looking forward to talking to you.
00:01:49
Speaker
And like you said, before we started recording, this is a very broad topic.
00:01:52
Speaker
We could spend hours.
00:01:54
Speaker
So we're going to focus on some practical aspects.
00:01:58
Speaker
But as we start, I would like to ask you, why should intensivists care about this topic?
Pneumonia Definitions and Classifications
00:02:03
Speaker
Yeah, it's a great question, Sergio.
00:02:05
Speaker
I mean, I think that's very important for everyone working at the ICU today to realize that there is no infection more common than pneumonia being the reason to be admitted to the ICU in the entire planet.
00:02:20
Speaker
It is really quite common no matter where you live, which country you live, which continent you live.
00:02:25
Speaker
Pneumonia is going to be your most common infection coming to the ICU.
00:02:30
Speaker
And also, you know, not something to forget is the fact that pneumonia is the number one cause of sepsis.
00:02:41
Speaker
in the world.
00:02:43
Speaker
So the point is knowing that sepsis is killing 49 million people every year in the planet and knowing that the number one cause is pneumonia.
00:02:52
Speaker
I mean, I think that really should give pause to all of us working in the ICU to believe that the more we know,
00:03:00
Speaker
The more we learn, the more we know how to manage these patients, the more lives we're going to save.
00:03:04
Speaker
So pneumonia really is a critical topic for us to grow and learn and to do better.
00:03:12
Speaker
And as every topic that we discuss in life, but also in the ICU, even though it's something we see commonly, it's an onion with many layers that we'll try to peel today, correct?
00:03:23
Speaker
Absolutely.
00:03:25
Speaker
Absolutely.
00:03:27
Speaker
Could we go over definitions of the types of pneumonias that we might see in the ICU and why that's important?
00:03:34
Speaker
Yes.
00:03:34
Speaker
So, you know, the definitions have evolved a little bit in the last few years, and I think that's a perfect timing for us to talk, Sergio.
00:03:43
Speaker
The definition of CAP in general, community-acquired pneumonia remains relatively stable in the sense that it is infection that affects the lung parenchyma, and it is caused
00:03:58
Speaker
in some place outside the hospital setting.
00:04:00
Speaker
So, you know, basically, it is a patient that already come and is admitted to the hospital with a lung infection that was acquired before the patient was hospitalized.
00:04:13
Speaker
So that's relatively straightforward in the sense that definitions have not changed too much.
00:04:20
Speaker
Now, what's not so straightforward is that
00:04:24
Speaker
the amount of things that can cause community-acquired pneumonia keep growing.
00:04:29
Speaker
So, you know, we saw a few years ago during the pandemic, so different viruses like SARS-CoV-2, different strains of influenza, and now we're seeing a respiratory syncytial virus.
00:04:39
Speaker
So the point is,
00:04:41
Speaker
Pneumonia is really not caused just by bacteria.
00:04:44
Speaker
It's caused by fungal and viral and parasitic organisms.
00:04:48
Speaker
So we are seen expanding a number of ideological agents that's causing a CAP.
00:04:55
Speaker
And sometimes that can bring some confusion to the definition of CAP.
Operational Definitions and Diagnostics
00:05:01
Speaker
HEP and VAP have evolved as well.
00:05:04
Speaker
So, you know, years ago, they were lumped all together.
00:05:08
Speaker
Everything was anybody that was that acquired a, you know, a lung infection in a hospital, especially being in a hospital for more than 48 hours.
00:05:19
Speaker
were pretty much labeled as either a hospital car pneumonia or venilator associated pneumonia.
00:05:24
Speaker
But with the last guidelines in which I was one of the co-chairs, the IDSA American Thoracic Society guideline done in 2016, we decided to...
00:05:35
Speaker
make the definition a little more refined, a little more practical in the ICU as well.
00:05:40
Speaker
What we did, we separate HEP and VAP in the sense that you could have a HEP that end up with intubation.
00:05:47
Speaker
You could have a VAP that really was not born of a HEP.
00:05:51
Speaker
So this is getting a little bit confusing because there's so many abbreviations here.
00:05:54
Speaker
But let me just try to explain a little more specifically.
00:05:58
Speaker
So hospital acquired pneumonia,
00:06:01
Speaker
is defined as infection, a lung infection, acquired when the patient has been more than 48 hours in the hospital.
00:06:10
Speaker
So that's possible that, so in that case, could be that the patient is developing HAP without the need for intubation, or the patient developed HAP, that means got infection before getting intubated and that needed the intubation after being diagnosed with hospital coronary monos.
00:06:27
Speaker
So that would be a HAP,
00:06:29
Speaker
that was subsequently needed to be intubated.
00:06:33
Speaker
So basically it is still a HEP, but now the patient has mechanical ventilation.
00:06:40
Speaker
Vain-lator-associated pneumonia is a situation in which the patient develops a lung infection that requires mechanical ventilation or invasive mechanical ventilation.
00:06:53
Speaker
And the patient develops an infection
00:06:56
Speaker
48 hours after being intubated so the bottom line here it's a little bit different in the sense that now the patient got intubated for multiple reasons not for infection uh and now two or days later the patient develops a a new lung infection so this is going to be called bin layer associated in the morning one thing sergeant if you allow me i want to i want to talk about is that there was before our guideline being published in town 16th the half fab guideline
00:07:24
Speaker
There was an old definition called age cap that probably you remember from the ICO times as well, is that the healthcare associated pneumonia that when we, when our panel, the IDSA ATS panel decides to evaluate the validity and the utility of this definition,
00:07:46
Speaker
We noticed that actually that definition really did not really help us to define which microorganisms were most common and did not help us to define which antibiotics should be used.
00:07:59
Speaker
Actually, that definition itself was leading to an unnecessary use of antibiotics, especially in emergency rooms, because
00:08:09
Speaker
Sometimes patients would be coming just from, let's say, a nursing home or a dialysis center, infusion center, and right away they would be labeled as age gap and get very broad-spec antibiotics.
00:08:19
Speaker
We noticed that actually these patients did not need broad-spec antibiotics, and we decided to, after a very extensive systematic review, we decided to remove that from the guideline, and we decided
00:08:29
Speaker
we actually, we suggest the CAP guideline, the CAP panel members to reevaluate that to see if it would be useful for them.
00:08:38
Speaker
And a couple of years later, the CAP guideline reevaluate that and decide that actually age CAP should not be enacted as well for community acquired pneumonia.
00:08:48
Speaker
So the bottom line is,
00:08:50
Speaker
each gap is extinct, does not exist for either HEP or VAP or CAP.
00:08:55
Speaker
And this is really important because it's not really a reason to justify broad-spec antibiotics anymore because these patients are not at higher risk than the general population for multidrug-resistant infections.
00:09:06
Speaker
So I think this is something important for us to clarify, Sergio.
00:09:10
Speaker
Excellent.
00:09:11
Speaker
And I agree.
00:09:12
Speaker
Very important.
00:09:14
Speaker
Why is it important to have these operating definitions and how does it impact our empiric initial therapy?
00:09:24
Speaker
Yeah, so this is, you know, it's important because once we have this operation of the definitions, we can kind of direct the diagnostics and therapeutics in a much better way.
00:09:40
Speaker
For instance, you know, if you're thinking about, let's say, community cord pneumonia in the sense that the patient likely acquired the infection before coming to the hospital,
00:09:50
Speaker
your diagnostic focus is going to be mostly on microorganisms that live in the community.
00:09:57
Speaker
So you're going to be thinking about strep pneumonia, you're going to be thinking about influenza, you're going to be thinking about
00:10:05
Speaker
different exposures where the patient could have been.
00:10:07
Speaker
So all these things.
00:10:08
Speaker
So you're going to have to really direct your bedside history and physical examination towards, you know, causes that were required before the patient comes to the hospital.
00:10:21
Speaker
Once you make the once you make the once the patient fulfill the definition of HEP or VEP,
00:10:28
Speaker
your history and your physical are going to be much more focused on the immediate sources of these infections that should be very close to you in the hospital setting in the ICU or in the wards or in the hospital at work.
00:10:41
Speaker
So the point here is that it will change your diagnostic and therapeutic approach because you're going to have to really focus on the immediate sources of infection in somebody that has been in the hospital.
00:10:56
Speaker
I'm glad you asked this question, Sergio, because sometimes it sounds like this is just semantics and, you know, clinicians and scientists trying to just, you know, have some fun with this variety of definitions.
00:11:09
Speaker
But this is real.
00:11:10
Speaker
These are really practical and important definitions that will help us to direct our approach to our patients in the ICU.
00:11:19
Speaker
Excellent.
00:11:20
Speaker
And could you also talk a little bit about within CAP, within community-acquired pneumonia, there's obviously a range of severity.
00:11:27
Speaker
And in the ICU, we see the most severe types of pneumonia.
00:11:32
Speaker
And there is an entity known as severe CAP, correct?
00:11:35
Speaker
Mm-hmm.
00:11:37
Speaker
How do you think about that as an ID expert in critical care?
00:11:42
Speaker
So, you know, Sergio, this is, it's an evolving, a severe cap or S-cap is, it's an evolving definition.
00:11:49
Speaker
I think that it is fair to say that the, if you look at the literature, you're going to see, you know, a relatively diverse set of definitions, but I think it's fair to say that
00:12:04
Speaker
There are a few things that are quite common to most of the severe CAP definitions.
00:12:09
Speaker
So these are going to be patients that are going to be in a military hospital with severe hypoxia, so they will be requiring...
00:12:18
Speaker
either high flow non-invasive ventilation quite you know quite fast as soon they they get into the hospital sometimes they have to be transferred to the issue because they're severely hypoxic despite non-invasive ventilation
00:12:35
Speaker
These are the patients that usually I tend to think that you should really be way more immediate in terms of approaching them and defining the best management.
00:12:48
Speaker
Because once they have this progressive hypoxia, and being a little more specific,
00:12:54
Speaker
So you're going to see, you know, either by O2 sets or if the patient is intubated by ABGs, you're going to see usually PDF ratios and a PAO2, AFIO2 ratios on the range of hundreds to hundreds.
00:13:07
Speaker
These are going to be the situation where, you know, patients really are progressing relatively fast.
00:13:11
Speaker
And I think that's fair to say that this, to me, is going to be the most important part of the definition of CVR cap.
00:13:18
Speaker
And, you know, we could add different things.
00:13:20
Speaker
We could add, you know, biomarkers.
00:13:24
Speaker
We could add like white count.
00:13:25
Speaker
We could add CRP and ProCal and all that stuff.
00:13:27
Speaker
But I think it's...
00:13:28
Speaker
To me, nothing is going to replace the understanding that the patient really is getting dyspneic, hypoxic, and progressing
Diagnostic Approaches and Biomarkers
00:13:38
Speaker
quite fast.
00:13:38
Speaker
And I think that really, to me, is the hallmark of somebody that's developing severe CAP.
00:13:44
Speaker
And then we could, you know, we could add radiological findings by marker findings, but this is not going to change.
00:13:50
Speaker
The other thing that, to me, is really important, surgery, is especially before a patient gets into beta, if the patient starts developing hypotension,
00:13:59
Speaker
um you know that in in in that situation where now you're thinking that maybe the pneumonia is causing septic shock it's quite severe uh and even if the patient is not intubated what's not that uncommon if the patient has a um you know a good you know pulmonary physiology still uh without too many comorbidities they can develop septic shock without still progressing to invasive mechanic ventilation so
00:14:23
Speaker
It is an important sign of severe infection that cannot be missed as well, even if the patient is not intubated.
00:14:32
Speaker
So I would say still very practical, very old-fashioned, progressing severe hypoxia, progressing severe hypotension are going to be the big drivers for me to define that this patient has severe capping.
00:14:46
Speaker
And I don't think this is going to change in the short term, Sergio.
00:14:48
Speaker
Perfect.
00:14:49
Speaker
Let's talk about the initial management of ICU and pneumonia.
00:14:54
Speaker
And maybe if you could just give us an overview of what an appropriate initial diagnostic workup would be, and then we can dive into a little bit more about therapy.
00:15:04
Speaker
Yes.
00:15:05
Speaker
So, such diagnostic things are evolving in a very positive way.
00:15:10
Speaker
You know, we, so, you know, I mean, the bottom line is the history and the physics are gonna be very, very important.
00:15:19
Speaker
You know, basic things, let's say,
00:15:22
Speaker
you know, patients that have, let's say, you know, if the patient has a history of splenectomy, has a history of alcohol drug use, these patients are going to be more prone to encapsulated microorganism like streptococcus, streptococcus pneumonia.
00:15:36
Speaker
So these are
00:15:37
Speaker
situations where you don't want to miss because strep pneumonia is a deadly bug.
00:15:42
Speaker
It can be really life-threatening and severe.
00:15:45
Speaker
And so if the patient has risk factors or certain infections, we're going to talk a little more about this when we talk about non-respondent pneumonia as well.
00:15:53
Speaker
But this part of the history is really important.
00:15:57
Speaker
As an ICU doc, as an ID doc, getting good history is going to be, for CAP specifically, is going to give you a very, very, very good advantage in terms of refining the best therapy that you're going to use, the empiric therapy, because at that time, likely you're not going to have the diagnosis.
00:16:15
Speaker
Probably it's going to take another day or two until you have the diagnosis, and if you're lucky, because the reality is when you look into patients,
00:16:22
Speaker
sputum cultures is going, you know, the amount of, the proportion of patients are going to have a positive sputum culture is going to be probably in a range of 20, 30% in a way.
00:16:31
Speaker
So the reality is still in most places of the planet today, you know, close to two thirds of these patients, you're not going to have a specific etiologic microorganism.
00:16:41
Speaker
So you have to deal with your best empirical therapy, your best history, your best physical examination.
00:16:47
Speaker
This is not going to change in the short term.
00:16:50
Speaker
But the good news, Serge, is that we have a, you know, still we have the labs, we still have like basic labs, you know, white count, a number of bands, number of neutrophyses for the patient.
00:17:04
Speaker
Let's say for the patient's neutropenic from some chemotherapy or cancer, you know, patients are being compromised.
00:17:09
Speaker
This is going to help to understand what kind of risks the patient has.
00:17:12
Speaker
If the patient has a very severe leukocytosis, it's going to give with bandamia, it's going to give a sense that this is a very acute and progressive infection.
00:17:21
Speaker
Biomarkers like C-reactive protein, procalcitonin can be complementary to try to understand the extent of the disease, the extent of the inflammation towards the disease, but they alone will not really give the whole picture.
00:17:32
Speaker
Remember, all these biomarkers will be complementary information to you.
00:17:38
Speaker
So they can help in diagnose, for instance, but one thing that's very important, especially nowadays, Serge, I want to emphasize this, especially when it comes to diagnosis.
00:17:48
Speaker
You know, it's not uncommon for me to see patients coming with acute pneumonia and actually quite ill, still without too much leukocytosis or a normal Procao or normal CRP.
00:17:59
Speaker
Because remember, it takes a bit sometimes, especially if the patient has some comorbidities, it takes sometimes that they were too
00:18:06
Speaker
for us to see some of these inflammatory markers to go up.
00:18:09
Speaker
And so don't mislead yourself with these negative biomarkers because I see tons of patients with severe pneumonia with no locus cytosis and normal procal and normal CRP when they're admitted to the hospital.
00:18:21
Speaker
and that should not detract you from actually following up your diagnosis and treating these patients aggressively because these biomarkers, they are not reliable, especially in the very beginning of the disease.
00:18:34
Speaker
They are not reliable in terms of ruling in these infections.
00:18:38
Speaker
So this is something that I think it's very important for us to remember.
00:18:42
Speaker
The other thing I want to mention, Sergio, is that we...
00:18:46
Speaker
We're still learning, but it's a growing process in which we have the
00:18:51
Speaker
If you're able to get the sputum, we have now these PCR panels.
00:18:55
Speaker
We have several platforms with PCR, something that we didn't have until just a few years ago.
00:19:01
Speaker
So once we get this sputum, we not only are able to do gram stains that can be quite useful in cultures, but we can do a PCR.
00:19:09
Speaker
So we have the PCR of the sputum, we have the PCR of the nasopharyngeal area as well.
00:19:15
Speaker
So we can...
00:19:16
Speaker
actually screen closer to any different microorganisms, both in the nasal swab and in the pneumonia panel.
00:19:22
Speaker
So this is, to me, has been quite useful because we can potentially have the potential ideology of CAP, you know, in the first, you know, few hours of the patient admission.
00:19:36
Speaker
So it's kind of a
00:19:38
Speaker
almost shocking thinking about how I was, you know, I practiced my medical school so many years ago in which we didn't have any of this.
00:19:46
Speaker
So I think that these things are evolving, these things are changing.
00:19:51
Speaker
The data still is, you know, is evolving.
00:19:56
Speaker
But I think that all these PCR techniques, they will become a little more a part of a routine.
00:20:04
Speaker
And again, none of them
00:20:06
Speaker
will be alone and giving you the final diagnosis of anything but they will be complementary to your you know you could have a positive swab for something in somebody that's colonized with the virus or colonized with the bacteria but if you don't if you don't put together that PCR panel with the clinical picture of the patient you may end up not helping a patient or even harming so the point is
00:20:26
Speaker
All these sophisticated technologies are, I think they can be quite useful, but again, in the context of the clinical assessment.
00:20:35
Speaker
So I would say that diagnostic-wise, that's going to be pretty much the, and sure, we don't want to forget
Radiology and BAL in Diagnostics
00:20:42
Speaker
the radiology.
00:20:42
Speaker
The radiology is going to be key here because a lot of times our physical examination, especially of the lungs,
00:20:51
Speaker
It's quite limited and the chest x-rays will be usually the first kind of approach, simple, fast.
00:20:58
Speaker
And the chest x-rays can show clearly an extensive pneumonia, but also chest x-rays can potentially not be that useful in the beginning of the picture.
00:21:12
Speaker
So, you know, if you still have a high, what you call pre-test reliability, if you have a high suspicion of pneumonia, a chest x-ray alone, it will not roll out the pneumonia.
00:21:24
Speaker
I think it's important for you to think that you have all the rights to move forward and think about a CT scan or maybe a lung ultrasound POCUS that can give you also some other information.
00:21:35
Speaker
But
00:21:36
Speaker
Um, you know, it's never get detracted by a normal chest X-ray because a normal chest X-ray, um, um, alone is not, um, you know, is not a sufficient through a lot in the morning if you have a high clinical pre-test vulnerability.
00:21:51
Speaker
So it can be very useful if it's positive and maybe not so useful if it's negative.
00:21:56
Speaker
So once you put together the, um, history, the clinical, uh, the laboratory and the radiology, uh, uh, factors altogether, then, um,
00:22:05
Speaker
that's going to give you a much better sense of how to approach.
00:22:09
Speaker
And we're going to talk a little more about the empiric antibiotics.
00:22:12
Speaker
You want me to talk about empiric antibiotics a little bit now, Sergio, or later?
00:22:16
Speaker
Yes, in a second.
00:22:17
Speaker
I wanted to ask you, and we'll talk about VAP and other situations a bit later, but my question for community-acquired pneumonia in the ICU, when do you push for a little bit more aggressive diagnostics like maybe a BAL?
00:22:33
Speaker
Yeah, so the BAO, Sergio, is usually, you know, I'm not overly excited about doing a BAO right in the beginning, especially because these patients are quite ill if they're not.
00:22:45
Speaker
I mean, if they're intubated, I mean, it's a no brain.
00:22:49
Speaker
If they're intubated, I would get a trach aspirate right away.
00:22:52
Speaker
You know, as soon as we get the two bean, we're going to get a trach aspirate because it's
00:22:56
Speaker
The reality is the tracheasteride can be incredibly informative at that point, and it probably is going to be as informative as BAL at that point.
00:23:04
Speaker
But usually, I tend to be a little more aggressive in terms of looking for a BAL or a mini-BAL when the patient is not responding to the initial therapy.
00:23:18
Speaker
So usually, I don't go...
00:23:20
Speaker
First, as with a bronchoscope, one before intubation, because likely these patients are quite vulnerable and very ill.
00:23:28
Speaker
Then if you're going to do a bronchoscopy, likely the patient will remain intubated.
00:23:31
Speaker
And if they're intubated, they'll get a trachea asparta, as I do with probably most of the pneumonies in ASU.
00:23:37
Speaker
But if the patient is not responding to my initial approach, then
00:23:44
Speaker
that's going to be the way that I'm going to think about moving towards a more invasive diagnostic tool.
00:23:49
Speaker
But bronchoscopy is not really part of my initial approach because it is, at least the evidence that we have, it is something that's not going to change your management in that first 24-48 hours.
00:24:02
Speaker
Excellent.
00:24:04
Speaker
Now I think we could talk about empiric antibiotic therapy and how you would approach that.
Empiric Antibiotic Regimens
00:24:10
Speaker
So, Sergio, the, you know, the, it's sure that it's going to vary a little bit about where you live because, you know, some of us live in geographic areas with more resistant organisms or less.
00:24:24
Speaker
For instance, you know, if you live in South Korea or Taiwan, they have a very...
00:24:28
Speaker
high incidence of resistant strep pneumonia.
00:24:30
Speaker
So they will have to be, you know, they have to approach a little bit different how they treat strep pneumonia there compared to how we treat strep pneumonia here in Nebraska and the States.
00:24:39
Speaker
So the point is,
00:24:41
Speaker
You have to know a little bit of your local community and what kind of infections they have in your geographic area.
00:24:49
Speaker
This is really important.
00:24:51
Speaker
But that being said, I would say, Serge, that in the vast majority of the planet, once you have a patient with CAP being admitted to your ICU, you're going to start a bit like them, either ceftraxone or cefetaxime, ceftaroline, and
00:25:08
Speaker
or M. subactam some the kind of the the usual antibiotics that are going to be quite useful in the situation in combination with the macrolide either is itromycin or clitromycin that's pretty much well you know most of the guidelines are quite consistent on this so you're you're on a kind of approach
00:25:27
Speaker
both the beta-lactam macrolides because you're going to catch most of the bacterial, both the typical and atypicals like Legionella, Mycoplasma and so forth.
00:25:35
Speaker
So this is reasonably, I would say it's a reasonable approach that I do here in Omaha and most of the guidelines are quite consistent.
00:25:46
Speaker
What gets a little tricky is sometimes when patients cannot receive some of these drugs and that really adds a little layer of complexity.
00:25:55
Speaker
But I would say, you know, it's fair to say we don't need to get into the, you know, kind of the details of the types of allergy and so forth.
00:26:05
Speaker
I would say that beta-lactamins and macrolides are going to be the biggest region for most of the issues in the planet.
00:26:13
Speaker
Tetracyclines like doxycycline can be quite useful as well if you cannot use macrolides.
00:26:21
Speaker
And also tetracyclines can potentially even have better activity against some of the mycoplasma.
00:26:28
Speaker
It depends where you live, but they can be quite useful as well.
00:26:31
Speaker
So I think doxycycline,
00:26:34
Speaker
It's a drug that has not been much studied in the ICU, but I have a feeling that we're going to see more use of this drug in the future in the ICU because of this potential, if we have a higher prevalence of some of these atypical organelles like mycoplasma, it's going to be useful.
00:26:53
Speaker
So I would say that's a good general approach for community-like bar pneumonia in general, Sergio.
00:27:01
Speaker
What would you consider MRSA coverage in a community acquired pneumonia?
00:27:06
Speaker
Well, that's a very good question, Sergeant.
00:27:10
Speaker
I might say, generally speaking, we don't.
00:27:13
Speaker
But that being said, we have to be sensible to the fact that some of our patients maybe have had exposure to MRSA
00:27:25
Speaker
by different reasons either the patient has some kind of comorbidities some kind of underlying condition that leads to have if the patient a history of have let's say if the patient comes around a bit a patient already had MRSA infection in the past either pneumonia or endocarditis or something or the patient had a history of substance drug use or something that
00:27:47
Speaker
put the patient at very high risk for MRSA.
00:27:49
Speaker
I think that it's quite reasonable to approach empirically.
00:27:53
Speaker
But again, this is going to be really important to know if the patient had a significant history, a risk for MRSA.
00:28:03
Speaker
I mean, overall, in general, if I don't have any kind of risk factors for MRSA, it's not going to be a bug that normally will go over for a cat.
00:28:15
Speaker
Andre, you mentioned a little bit about understanding your local kind of flora according to where you live.
00:28:22
Speaker
Could you share with us your thoughts on the antibiogram of the hospital?
00:28:27
Speaker
Something that obviously our ID colleagues are very well aware, but I believe that sometimes the intensivists forget.
00:28:36
Speaker
Yeah, I'm so glad you asked that, Serge.
00:28:37
Speaker
I mean, you know, in our 2016 IDSA-ITS HAP-VAP guideline, it was the first time ever that the guideline came up with the recommendation of local antibiogram.
00:28:53
Speaker
Actually, we recommended both to have an antibiogram in the ICU and in the wards in different units.
00:29:00
Speaker
separately, ideally, from the hostel because we, at that time, you know, the whole panel agreed that
00:29:09
Speaker
that would be the best tool that we could have in the ICU to manage empiric pneumonia.
00:29:14
Speaker
Both HAP and VAP.
00:29:19
Speaker
Since then, we've had many, many studies already being published showing the utility of having this antibiogram.
00:29:25
Speaker
So, if whoever's listening to us today, Serge, works in the ICU,
00:29:30
Speaker
with, you know, with a lot of pneumonia, I definitely would strongly recommend you to talk to your infectious disease team, your infection control microbiology, and ask how can you in the ICU can be provided as we are here, for instance, at the University of Nebraska every six months.
00:29:51
Speaker
We have an update of our units and awards in terms of, you know, what bugs have been culture and have been, you know, being positive here in the micro lab.
00:30:04
Speaker
So we have this list.
00:30:06
Speaker
of of percentage and and kind of prevalence that we have in a hospital it's incredibly useful because uh we you know we can we can be way more precise uh in terms of choosing the antibiotics we can be way more precise in terms of uh getting them right uh and and and managing our patients in a much more precise way so i think we can do better individualized personalized medicine
00:30:30
Speaker
And I think we can get the infection cleared much faster because, you know, if you start with the right antibiotics, you're going to definitely speed up the recovery process of your patient with severe pneumonia.
00:30:42
Speaker
So local antibiograms, ideally ICU antibiograms, wards, antibiograms are incredibly useful and they should be standard of practice in every single hospital of this planet.
00:30:56
Speaker
And that's the best way because
00:30:59
Speaker
The truth, Serge, is that most of us in the ICU will not have the diagnosis immediately.
00:31:05
Speaker
We're going to have to start an empirical approach.
00:31:08
Speaker
And in order for the empirical approach to really do well and be successful, you have to know what is your flora in your ICU to get antibiotics right.
00:31:18
Speaker
So this is something that I'm going to emphasize forever and ever because it is really, really important.
Role of Corticosteroids in CAP
00:31:25
Speaker
Perfect.
00:31:26
Speaker
Before we move on to VAP, over the last couple of years, there's been a lot of discussion about the role of corticosteroids and septic shock, but also some emerging trials in pneumonia with COVID.
00:31:41
Speaker
We went through this.
00:31:43
Speaker
From your perspective, for severe community-acquired pneumonia, is there a role for corticosteroids and what is it?
00:31:51
Speaker
Yeah, so...
00:31:52
Speaker
Serge, it's a difficult question because nobody knows yet, even though there are.
00:32:00
Speaker
So the studies are quite contradicting.
00:32:03
Speaker
And we had the Cape Cod and had the escape two randomized trials recently done.
00:32:09
Speaker
one fully negative, one fully positive, fully positive, positive in the sickest patients.
00:32:13
Speaker
But, you know, basically, you know, why I'm telling that, I'll give you an example.
00:32:18
Speaker
In Cape Cod, in the French study, these are patients, the patients with the most severe cap were the patients that had, you know, showed some benefits from steroids.
00:32:27
Speaker
But the issue here is that they had to screen about 6,000 patients, 6,000 ICU patients in order to end up with 800.
00:32:35
Speaker
So why that's a concern to me is because, you know, most of the patients that they screen, they could not, you know, they could not really put in the study in the sense that that brings the generalizability of these results to my ICU quite questionable.
00:32:50
Speaker
You know what I'm saying?
00:32:50
Speaker
The problem is when you end up with a very small selected patient population.
00:32:55
Speaker
It's very hard to know if that patient population can be translatable to my patient population, my ICU enoma.
00:33:02
Speaker
And that's the concern I have when we have studies like this in the sense that they are so strict in their inclusion criteria that you cannot extrapolate that easily.
00:33:12
Speaker
So that's the concern I have.
00:33:13
Speaker
The other concern I have is that another randomized trial, the ESCAPE, that is also large and well done,
00:33:19
Speaker
didn't show any benefit so i think still the verdict is out still we don't know for sure but i i think it's reasonable to say um sergey that when you look at cape cods the patients that likely had more benefits were the ones that had the pdf ratio less than 150 that's so these are incredibly old patients and patients that had a crp greater than 15 and they were not intubated yet so my my take
00:33:44
Speaker
from Cape Cod trial is that if the patient has appropriate antibiotics, you know that you're giving them at least your best empirical approach.
00:33:55
Speaker
The patient has a PDF ratio less than 150, a CRP gradient 15, not intubated.
00:34:00
Speaker
It's a patient that I give consideration to give steroids in my ICU.
00:34:03
Speaker
But other than that, and these are incredibly rare patients, very, very rare patients.
00:34:07
Speaker
Most patients are not that ill.
00:34:10
Speaker
And to be honest with you, a lot of these patients are going to be already in septic shock, in which septic shock, you know, following the SurviveSeps campaign at that point.
00:34:18
Speaker
It's not unusual that they're already going to be in steroids for refractory septic shock.
00:34:23
Speaker
So,
00:34:24
Speaker
Kind of that wraps up a little bit my, you know, kind of my take on this is, you know, nobody knows for sure if steroids are beneficial in this instance.
00:34:36
Speaker
But if they are beneficial, they're going to be beneficial in the most two patients still very importantly that are receiving the most appropriate antibiotics.
00:34:46
Speaker
Because if they are not receiving the appropriate antibiotics, you can give how much steroids you're going to give.
00:34:50
Speaker
The patient is not going to do well.
00:34:52
Speaker
I think that's important, right?
00:34:53
Speaker
As a determinant of good outcomes is the early initiation of antibiotics that cover the pathogen that's causing the problem.
00:35:01
Speaker
Absolutely.
00:35:02
Speaker
Absolutely.
VAP Risks and Diagnosis
00:35:03
Speaker
Let's dive into a ventilator-associated pneumonia, VAP, and maybe start with an overview of the pathophysiology and why do patients on ventilators develop these pneumonias?
00:35:16
Speaker
Yeah, so, you know, Sergio, the unfortunate one, you know, when you have an endotracheal tube, we, you know, we block a lot of the defense mechanisms that we have normally, all the seed and everything else, all the secretions that normally come up that we don't, you know, we don't even feel it.
00:35:32
Speaker
We are talking now, we have, you know, our lungs are, you know, being self-clean 24-7.
00:35:35
Speaker
And, you know,
00:35:39
Speaker
So basically, we stop all these defense mechanisms of the upper arrays when you have ET tube.
00:35:46
Speaker
And that really makes the patients more vulnerable to have infections because you lose a huge defense mechanism.
00:35:54
Speaker
On top of that, I mean, and we could talk for a little longer about this, but on top of that, some of these bugs will adhere to the tube, will potentially, you know, lead to all kinds of different colonizations, biofilms and different things, the same way we see with, you know, with endovenous scatters as well.
00:36:11
Speaker
So there are different things that can potentially...
00:36:14
Speaker
become part of the AT tube and that potentially can contribute as well.
00:36:18
Speaker
But I would say in general, Sergei, in general, the way we learned throughout the last 20 years or so,
00:36:25
Speaker
the most the majority of these um uh hostile acquired pneumonia and later associated pneumonia are going to be by microspiration and meaning that's going to be a very uh you know usually it's not going to be a very large amount it's going to be a small amount of bugs that are going to be migrating from the upper arrays to the lower arrays and and then you say well you know if this is the if this is the case then why you know why we see a different different bugs right why you why we don't see the usual community acquired bugs because
00:36:56
Speaker
And this is a good question.
00:36:57
Speaker
The reason why is because once you're in a hospital, your mouth flora, your upper airway flora changes.
00:37:04
Speaker
The longer you stay in a hospital, the more your microbiome, your normal flora in your mouth is going to change and your usual gram-positive Xenobo bugs that you have in a mouth are going to be replaced by a lot of gram-negatives.
00:37:17
Speaker
And that includes Pseudomonas, Clab, all this stuff.
00:37:20
Speaker
So it's basically, it's kind of the environmental change, that kind of critical illness change.
00:37:26
Speaker
And so now you get, you know, your flora chains.
00:37:31
Speaker
And the longer you stay in a hospital, the more chains you're going to have them.
00:37:34
Speaker
there are some very uh very good studies done in germany about 10 15 years ago showing the chains when they coach this patient on a regular basis when they're in the icu on their upper flora so the idea here is that you will be colonized with a different flora and this different flora will be the gram negatives that usually are going to be associated with um with nosocoma pneumonia so that is
00:37:58
Speaker
in you know in short the kind of the uh the pathology and the physiopathology of these patients and remember for every day that you remain debated that you increase your probability of developing as a common infections by something range of five to ten percent so it's it goes up pretty fast so it's it's just that's why i think one of the biggest jobs we have in the issue is
00:38:20
Speaker
is to be really, you know, to be very precise about extubating patients when they don't need anymore to make an ventilation because the longer they stay in the ET tube, the higher probability of developing a nosocom infection.
00:38:38
Speaker
What are the diagnostic criteria, Andre, for VAP?
00:38:43
Speaker
So, you know, the VAP will be a little bit changed in a sense compared to CAP because, you know, the vast majority of these patients will be intubated.
00:38:53
Speaker
So the way that we...
00:38:55
Speaker
We analyzed this whole evidence in the 2016 HEPF-EFCA line was to look for potential differences between sputum and trache aspirate and BAL, mini-BAL.
00:39:10
Speaker
And so we in quantitative cultures, qualitative cultures, we look into all the possibilities.
00:39:17
Speaker
And once the panel really did this very extensive systematic review, Serge, we came up with the conclusion that actually there is no outcome change.
00:39:28
Speaker
Once you make the diagnosis of VAP,
00:39:30
Speaker
there is no outcome change differences between collecting a trach aspirate and collecting a BAL or a mini BAL.
00:39:39
Speaker
So basically, at that moment of diagnostics, whatever test you do is not going to change the outcome.
00:39:48
Speaker
So that's why we made the recommendation of trach aspirate because it's much less invasive than
00:39:53
Speaker
going directly for bronchoscopies in its patients.
00:39:55
Speaker
And the trachysprate, again, very important as we recommended the guideline, the trachysprate has to have quality, has to have enough white cells for the microlaptor process, usually more than 20, 30 white cells.
00:40:08
Speaker
very little epithelial cells, less than 10 epithelial cells, that means this is not a bad respiratory sample.
00:40:14
Speaker
And with that good sample, you can do either a semi-quantitative or quantitative culture, and all of them are going to pretty much be as useful in terms of outcomes compared to the studies that used bronchoscopies and invasive BAL collection.
00:40:33
Speaker
So that's kind of still remains the remains.
00:40:36
Speaker
There's no data, no evidence that changed that recommendation from 2016.
00:40:42
Speaker
And we'll talk a little more, we'll talk back about bronchoscopies once we have these patients, the proportion of patients that do not respond to initial therapy.
00:40:51
Speaker
But initial therapy, initial diagnosis is going to be tracheasperate pretty much in any place.
00:40:56
Speaker
You don't need any special technique, just get a good sample, bring to the lab, and ideally you just can do either a semi-quantitative or quantitative culture.
00:41:08
Speaker
You do a gram stain, and that's going to be probably one of your best tools to narrow down and be more precise with your antibiotic approach.
00:41:20
Speaker
Now, very important, Sergio, I want to bring this up to is that the...
00:41:29
Speaker
the history and the physical are going to be really critical for, uh, uh, for the therapeutic approach.
00:41:35
Speaker
I don't know if you want me to just start talking about the therapeutic approach at this point.
VAP Treatment Strategies
00:41:40
Speaker
Sure.
00:41:40
Speaker
Why don't we talk a little bit about, um, therapeutic approach for VAP and how you, you, you would think about this.
00:41:48
Speaker
So, so one thing that I want to, I want to bring, um, uh, um, to everyone, Sergio is that, uh,
00:41:57
Speaker
I'm very proud to tell you that the way that we kind of put this together in the 2016 guideline was something that really changed the practice in many, many places in the world.
00:42:06
Speaker
And I think it's really for better because there were three different things that we, three factors that we put together in order to choose the empirical treatment.
00:42:16
Speaker
One is epidemiologic, right?
00:42:17
Speaker
So if the patient, if the patient now has VAP and it is a patient with a history of IV antibiotics in the last 90 days, right?
00:42:27
Speaker
33 months, or if the patient has been hospitalized for more than five days, that is a epidemiological feature to tell that this patient has a risk of developing a MDR infection.
00:42:41
Speaker
So this is important, but this is a patient that has been exposed to antibiotics and has been in the hospital for a long time.
00:42:47
Speaker
Number two, factor number two, local antibiogram.
00:42:50
Speaker
As we talked before, local antibiogram is going to be
00:42:53
Speaker
key for you to know if your patient now in the ICU is at risk for multi-drug resistant infection or not so knowing your your floor is going to give you that kind of perspective and we have very specific recommendation I got lying about what floor in what proportion floor should be should you be concerned about using a more expensive in in broad spectrum antibiotics third factor so that is very clinical
00:43:19
Speaker
if you're if you're diagnosing if you're suspecting the patient is developing vap and the the third factor is going to be and the patient has either septic shock or ards or acute or need for acute wind replacement therapy these three factors they will indicate that this patient may be at risk for a multi-drug resistant infection so these are
00:43:42
Speaker
measures of disease severity that we emphasize in the guideline that you don't have too much room to just kind of, well, let me start with something a little bit more mild and let's see what's going to happen.
00:43:57
Speaker
These patients are incredible.
00:44:00
Speaker
If they already have septic shock ERDS or AKI
00:44:04
Speaker
as part of the organ failure secondary to the pneumonia.
00:44:08
Speaker
It is this patient has a very high mortality.
00:44:12
Speaker
You don't have too much time to play around with antibiotics.
00:44:15
Speaker
So we tend to be way more aggressive and that's how we put this together guys.
00:44:20
Speaker
So basically three factors, epidemiology, local antibiogram and zisivir.
00:44:24
Speaker
These are gonna be the biggest factors to decide how broad you're gonna be in your antibiotic management.
00:44:32
Speaker
That being said, Sergio, the recommendation is going to be mostly for, in this situation, with these three factors, likely you're going to have to cover ideologies like Pseudomonas and non-enteric.
00:44:46
Speaker
So, you know, you can use either beta-lactams, you know, like Pitezo, Ceftazidim, Cephapine.
00:44:55
Speaker
You know, we don't recommend carbapendants right away, but if that's all you have, carbapendants, semipendom, aeropendants should be plenty, but we tend to reserve them
00:45:03
Speaker
after we try cephalosporins or penicillins.
00:45:05
Speaker
But basically, coverage for pseudomonas is going to be probably more important in this situation if you have a local antibiogram and disease severity or epidemiology.
00:45:18
Speaker
For MRSA infections, cover for MRSA is going to depend on your local antibiogram.
00:45:23
Speaker
And, you know, it's interesting, Sergeant, when
00:45:25
Speaker
We talk about this, and I've traveled the world and all continents talking about this, and I've always seen some ICU colleagues tell me, oh, in my ICU, you know, we see maybe one MRSA pneumonia a year or two.
00:45:38
Speaker
We don't, you know, we don't even start drinking myosin of a mastodonitis of the patient.
00:45:43
Speaker
So, again, it's the antibiogram.
00:45:46
Speaker
And, I mean, I've been in places where...
00:45:48
Speaker
They cannot just, you know, stop counting how many MRSAs and money they had, and they have to really, they don't have a choice other than starting my comycomycin when they have a suspicion of VAP.
00:45:57
Speaker
So I think the point here is knowing your local antibiogram, knowing your local flora in your hospital, in your ICU, is going to be key.
00:46:05
Speaker
And the other thing that we recommend in the guideline, it was a preliminary recommendation, but now we have way more data after 2016, Serge, is that if you have ways to screen the patients right away,
00:46:16
Speaker
uh you can do a piece a nasal pcr or nasal culture um if the foreign rsa specifically uh if the pcr is negative for mrsa there is there is a substantial amount of evidence showing that you are you know you can you're allowed to go ahead and not start or stop the uh the anti-staphylococcus coverage because it is very unlikely
00:46:40
Speaker
somebody's going to develop a MRSA VAP with a screening test negative.
00:46:46
Speaker
And again, that brings to mind, Serge, what we talked before, the importance of understanding what you have in your upper respiratory floor.
00:46:56
Speaker
And if you don't have MRSA there, it's unlikely that you're going to have in a lower floor.
00:47:00
Speaker
So that's kind of one thing that we do in our hospital as well.
00:47:03
Speaker
We quickly screen to define if you're going to need it or not.
00:47:07
Speaker
the anti-staphylococcal coverage.
00:47:09
Speaker
And that's great because, you know, if it is a negative, you minimize unnecessary drugs, you minimize toxicity of the antibiotics, and it's a win-win situation.
00:47:20
Speaker
Is there a role for a double gram negative coverage?
00:47:25
Speaker
Great question, Serge.
00:47:26
Speaker
So what we recommend in the guideline, and it still is the same recommendation up to today, is that if you have a high proportion of resistant pseudomonas in your ICU, we definitely recommend to go ahead and double coverage until you know what coach you're going to get from the trachea aspirate.
00:47:49
Speaker
If you have a very, very low prevalence of pseudomonas resistance to beta-lactams in RICU, we do not recommend double coverage.
00:47:59
Speaker
So again, coming back to the original questions, if you know your local antibiogram, if you don't have an antibiogram, you don't have a local antibiogram, you have somebody that's severely ill, especially with that disease severity, we suggest to double in coverage until we have the coacher's back.
00:48:16
Speaker
But remember, the double coverage, the same start for septic shock.
00:48:19
Speaker
The double coverage is only recommended when you do not know what you're dealing with and you believe that the patient is in a life-threatening situation.
00:48:28
Speaker
It's totally reasonable.
00:48:28
Speaker
There's nothing wrong with this.
00:48:30
Speaker
But it's not to increase the speed of clearance of the infection.
00:48:34
Speaker
It's not to kill more bugs.
00:48:36
Speaker
We do not achieve that, correct?
00:48:37
Speaker
So the point is very important for people to realize that given two, given three, given four antibiotics, we're not going to speed the clearance of the infection.
00:48:46
Speaker
That's not the goal.
00:48:46
Speaker
The goal here is that...
00:48:48
Speaker
if you're wrong in your empirical diet and treatment and you're given one drug uh you're going to be really wrong because the patient is going to get nothing right so that the advantage here of having double coverage is to make sure that you as a clinician is not making a mistake of giving monotherapy that is not going to help the patient because if you're giving a monotherapy that is wrong and now you get a culture two days but two days later three days later
00:49:10
Speaker
your chance of helping this patient is going to be minimized.
00:49:13
Speaker
It's going to be much smaller because now you did not treat this patient for two or three days.
00:49:17
Speaker
So that's why we emphasize that double coverage is for situations of very high risk for multidrug resistance, very ill patients.
00:49:26
Speaker
And your goal is to make sure that you have at least one of these antibiotics working.
00:49:31
Speaker
Once you have the culture back, and it happens all the time, Sergio,
00:49:34
Speaker
Once you have that pseudomonas back, multi-sensitive, let's say, you know, in the next day or two from the sputum culture, immediately I de-escalate and I stop the second antibiotics because you will not provide any further benefit continuing the second therapy.
00:49:50
Speaker
So this is very important to emphasize, Sergio.
00:49:54
Speaker
And you mentioned de-escalation.
00:49:56
Speaker
And when you have the culture, it should be easy, although I do believe that sometimes clinicians still have a hard time to de-escalate in very sick and critically ill patients.
00:50:06
Speaker
But if you have a culture, you have the roadmap to de-escalate.
00:50:11
Speaker
How do you approach de-escalation when the cultures are negative?
00:50:16
Speaker
Right, so when the coaches are negative, it's always more challenging, Serge, and I'm glad you brought this question because, you know, now you're a little bit in the dark, you know, so your de-escalation is going to really be dependent on the clinical progression and improvement of the patient.
00:50:32
Speaker
If the patient, you know, I'll give an example, if the patient is, you know, is doing fairly well, everything is doing well, the patient is, fever is down, hypoxia is improving, the patient always getting close to getting extubated,
00:50:44
Speaker
I'm very fast about de-escalating because I can see that the patient is moving so well along and is responding so well to antibiotics in the supportive care.
00:50:54
Speaker
So the clinical picture is going to be my gauge to de-escalate.
00:50:59
Speaker
And again, you have to read the patient.
00:51:01
Speaker
You have to be watching the patient very closely, 24-7.
00:51:05
Speaker
And that's going to be my biggest, you know, and believe me, if you have a patient with VAP that is not improving in, you know, in about three to four days, something's wrong.
00:51:17
Speaker
You're missing something.
00:51:18
Speaker
We're going to talk a little more about this, but, you know, it's not because the patient likely is needing another five, 10 days of antibiotics.
00:51:29
Speaker
You're missing something.
00:51:30
Speaker
You're missing a bug.
00:51:30
Speaker
You're missing something on infections.
00:51:32
Speaker
But the point is,
00:51:33
Speaker
Do not start to get desperate and adding and adding and escalating without looking for why the patient is not responding.
00:51:40
Speaker
But if the patient is responding, surgeon, in a nutshell, if the patient is responding to your initial empirical therapy, I am very fast about escalating because there is no reason to keep giving antibiotics when the patient doesn't need it anymore.
00:51:53
Speaker
Once the patient is getting to that point of getting extubated, getting out of the ICU, non-invasive pressors,
00:51:59
Speaker
You know, you know the patient now, the patient's own immune system is pretty much in charge of everything.
00:52:05
Speaker
And it is time for you to, to deescalate antibiotics.
00:52:09
Speaker
Now all you're giving is side effects.
00:52:10
Speaker
You're not giving too much benefit.
00:52:11
Speaker
So it is, it is something that you're going to have to do individualized in each patient.
00:52:16
Speaker
And you're going to have to follow the clinical picture.
00:52:18
Speaker
It's a little more complex because, you know, we don't have the cultures, but I think it's doable.
00:52:23
Speaker
And I do that all the time.
00:52:25
Speaker
How do you think of duration of antibiotics for severe CAP and for VAP?
00:52:31
Speaker
So, you know, it's for severe CIP, it's going to be, it's not going to change much.
00:52:37
Speaker
I tend to use kind of the five-day mark as a general five, you know, kind of just as a general approach.
00:52:42
Speaker
It depends, again, you know, if the patient is improving fast, it's going to be probably four or five days.
00:52:48
Speaker
If the patient is not improving fast, it's going to be maybe a little more, five, six, seven days.
00:52:52
Speaker
But again, it's going to be, each patient is going to be different.
00:52:54
Speaker
But I would say on average,
00:52:57
Speaker
something in the range of five, seven days is gonna be my upper limit for a cap.
00:53:02
Speaker
If the patient's not improving, I have to think that I'm missing something, something is not doing right because any patient that has a true community-acquired pneumonia and is receiving the proper antibiotics should definitely be pretty much resolved by that kind of five, seven days course.
00:53:23
Speaker
When it comes to VAP, Sergio, the way that we reviewed the data on the 2016 headline was that clearly most of the evidence, RCTs, observational studies showing that seven days should suffice for the vast majority of the patients.
00:53:38
Speaker
Again, individualized, we are not machines.
00:53:42
Speaker
You know, we can treat the patient for six days, for five days, for eight days, for nine days, but on average, it's going to be seven days.
00:53:49
Speaker
And if the patient is not improving within seven days, you better revisit your diagnosis, your history, what's going on, and because there's something that potentially
00:53:59
Speaker
you could be missing.
00:54:01
Speaker
So the point is simply prolonging antibiotics most of the times means prolonging the lack of a diagnosis and potentially missing what's happening to the patient.
00:54:11
Speaker
So that's why it's not simply say, oh, you know, these are infectious disease dogs that just want to save antibiotics.
00:54:17
Speaker
No, no, no, listen, I don't want you to miss the boat and what actually is happening to your patient in the ICU.
00:54:22
Speaker
And that's why it's really important for us to realize that prolonging antibiotics is not the solution.
00:54:28
Speaker
The solution is using the right antibiotics for the right time, but prolongation is not going to do anything.
00:54:33
Speaker
So there's no reasons today to give more than on average, you know, something range of seven days for the vast majority of patients with ventilator session and morning surgery.
00:54:46
Speaker
Perfect.
Non-Resolving Pneumonia Challenges
00:54:48
Speaker
And this is a good time to introduce the topic of non-resolving pneumonia, something you wrote about beautifully recently in a narrative review with other colleagues.
00:55:00
Speaker
How and when do you define a non-responder?
00:55:05
Speaker
So, Sergio, this is a gap in the literature, and that's why we wrote this paper for ICM.
00:55:11
Speaker
So there's a huge gap that is not
00:55:13
Speaker
a lot there that we can really, you know, be very precise about what it is.
00:55:19
Speaker
But that's why we decided to just take a nice group of people that really are, you know, very experienced on
00:55:27
Speaker
on the theme of pneumonia, very experienced in seeing patients with pneumonia.
00:55:30
Speaker
These are, you know, a combination of intensivists and pulmonary docs and ID docs.
00:55:36
Speaker
It's a nice combination of different specialties.
00:55:39
Speaker
And we just try to come up with something that could be didactic and helpful to clinicians at a bedside, especially in patients, in clinicians that see patients with severe pneumonia.
00:55:51
Speaker
So, Sergio, the way that we approached was that, you know, usually patients that are not responding in the 48, 72 hours is how we define that you should be kind of free thinking about what you're doing.
00:56:07
Speaker
Because the vast majority of patients, either CAP or VAP, when you get into that kind of two to three day mark, you should be seeing things in the right direction.
00:56:18
Speaker
When you see things in the wrong direction, what I mean about the wrong direction, correct?
00:56:21
Speaker
So basically fever is not coming down.
00:56:24
Speaker
The white count is not coming down.
00:56:26
Speaker
Biomarks like CRP or ProCal are not coming down or going up.
00:56:31
Speaker
And, you know, level of hypoxia, PDF ratio, things are not really moving in any better situation in 48, 72 hours.
00:56:40
Speaker
So when you get this kind of combination of, you know, not improving clinically, not improving laboratory, radiology is a little more complicated because radiology is not going to improve that fast.
00:56:51
Speaker
So
00:56:53
Speaker
It's unlikely that even if you did x-rays every few hours, it's unlikely it would help you because x-rays don't change that much unless there's some kind of complication.
00:57:06
Speaker
But the clinical picture, the laboratory picture, and also microbiology is not going to help you too much because getting another sputum or doing another swab is not going to help if you already have the ideology or you already did the diagnostic.
00:57:19
Speaker
So the bottom line is going to be your clinical experience.
00:57:22
Speaker
And in your laboratory, it's going to give you a sense of what's going on, why this patient is not moving in the right direction.
00:57:30
Speaker
And usually, the way we put in this paper is that between 48 and 72 hours should be the critical time for you to see the change.
00:57:40
Speaker
Now, very important, Serge, is that the non-responding rate varies very much by the ideology.
00:57:48
Speaker
So patients with CAP
00:57:51
Speaker
I'm going to have a usually a prevalence of something range of 15 to 25 30 percent of non-responding rate while patients with happen evap are going to be about 30 40 percent so why this is important is because the non-responding rate is going to be more prevalent in the hospital car pneumonia and ventilator such in one because these are sicker patients with a lot of other comorbidities and that's why we see this now
00:58:18
Speaker
Delving into the non-responding pneumonia, Sergio, I think it's also very important as a clinician, and I practice that every day because this is really important, is you have to realize that there are patients that maybe will have a delayed recovery.
00:58:33
Speaker
And so, for instance, patients with advanced age, patients with alcohol use disorder, patients with COPD or, you know, have smoking history, patients with heart failure, chronic heart failure, patients, you know, with pulmonary edema, diabetes, immune suppressions, solid organ transfer patients, cancer patients.
00:58:52
Speaker
So you have to put in perspective as some patients likely will take a little longer to respond compared to others.
00:58:58
Speaker
So if you get somebody that is, you know, 85 years old with history of diabetes, hypertension, heart failure,
00:59:05
Speaker
you know that that pneumonia is going to take longer to resolve than somebody that is 35 years old without comorbidities is coming to rescue with, you know, with a community-acquired strep pneumonia.
00:59:16
Speaker
So this is, so I'm putting in perspective always the host, the patient, you know, that's very important.
00:59:22
Speaker
So that kind of gives you a sense of the speed of recovery.
00:59:26
Speaker
Yeah.
00:59:26
Speaker
The other thing that's very important, Sergio, is the disease severity, correct?
00:59:31
Speaker
If somebody comes with a multilobar pneumonia, you know, very extensive process, highly hypoxic.
00:59:39
Speaker
even if the patient is not getting to bed, it's very likely this patient will take a little longer to have a delay to recover, a little longer to respond.
00:59:46
Speaker
So put in perspective, compared to somebody that comes with, you know, one lobe infection, require a nasal can of, you know, like three liters, comfortably see, you know, laying down in bed.
00:59:57
Speaker
So,
00:59:58
Speaker
It's two different patients, correct?
01:00:00
Speaker
Even though you can have both patients with the same etiology, the same haemophilus influenza, the same strep pneumonia, if one has, you know, two liters of oxygen laying down in bed, the other one is, you know, in 50% high flow with 50 liters, you know,
01:00:16
Speaker
that the recovery process is going to be different, correct?
01:00:18
Speaker
Because they are starting, you are starting to see the patients in a different time, in different part of the natural history of the disease.
01:00:26
Speaker
The third factor that is going to be very important to define non-responding pneumonia, Sergio, is the care, the care that we provide in this room.
01:00:34
Speaker
Three things are going to be important in the care we provide to this you.
01:00:38
Speaker
One is going to be the resuscitation support.
01:00:40
Speaker
Correct?
01:00:42
Speaker
If you're not giving proper amount of fluids, if you're not giving proper amount of oxygenation to these patients, supportive care.
01:00:50
Speaker
Correct?
01:00:50
Speaker
All these things, oppressors, whatever the patient needs.
01:00:53
Speaker
So if the patient is being under-resuscitated, likely the patient is going to have a delayed recovery.
01:00:58
Speaker
So that could be a reason for not responding.
01:01:01
Speaker
Related to care, antibiotics.
01:01:04
Speaker
You know, this is part of my expertise.
01:01:06
Speaker
I mean, right, you know, choosing the right antibiotics is the first step, correct?
01:01:11
Speaker
So looking for your local antibiogram, everything else, but also very important, Sergio, is knowing that the antibiotics that you're giving are in the proper dose to penetrate in the lung parenchyma.
01:01:22
Speaker
A lot of times people forget that, you know, they look at these little booklets with, you know, kind of standard dose of antibiotics.
01:01:28
Speaker
Remember, you have somebody with sepsis, with septic shock, with a VAP.
01:01:31
Speaker
These patients have a very large volume of distribution.
01:01:34
Speaker
These patients will need high dose of antibiotics, not only because they have a very large volume of distribution, but also they have to penetrate in the lung parenchyma.
01:01:43
Speaker
Be careful.
01:01:44
Speaker
Sit with your pharmacist and look into how to really be aggressive in terms of giving the proper dose of antibiotics to this patient.
01:01:53
Speaker
This is really, really important because once you under those, even if you give the right antibiotic, if you under those patients, likely they're going to have a delayed recovery and they're going to look like non-responding.
01:02:03
Speaker
The third factor I want to mention is, I'm sure, is the, on this, is source control.
01:02:11
Speaker
So just so, you know, if the patient maybe is not responding because the patient has, empyema has a large plurifusion or lung abscess or necrotizing pneumonia.
01:02:23
Speaker
So these are things that potentially, even if you're given the right antibiotic,
01:02:28
Speaker
Even if you're providing the right resuscitation measures, if the patient has a lack of source control from the same infection, that's going to be another reason for delayed recovery and potentially being, you know, being labeled as a non-responent of the money.
01:02:45
Speaker
So these are the things that I bring to you that are going to be important.
01:02:48
Speaker
It's going to be...
01:02:49
Speaker
you know, pre-existing factors, comorbidities, disease severity presentation, and care-related in terms of resuscitation, antibiotics, and source control.
01:03:01
Speaker
These are going to be the things that are going to help you to define who is and who is not responding to the pneumonia treatment, Sergio.
01:03:09
Speaker
Once you define as a non-responsive patient to appropriate treatment, like you, like you, you clarified, what are the causes or the differential diagnosis that we should consider?
Non-Infectious Pneumonia Considerations
01:03:23
Speaker
So I would say that there are a couple of things that are going to be very important.
01:03:27
Speaker
You want to, so I think that's the two things that you want to think in your mind when you're in the situation, so it's the following.
01:03:33
Speaker
Um,
01:03:36
Speaker
Am I missing something or what could I be missing?
01:03:39
Speaker
So I think the two misses, the two big misses is going to be, is my missing infectious disease related or is my missing non-infection disease related?
01:03:47
Speaker
So I think these are going to be the two big buckets that are going to be, you know, you're going to be thinking about this situation.
01:03:53
Speaker
So...
01:03:54
Speaker
What things could I be missing that are infectious related?
01:03:57
Speaker
So one is if you're, you know, given the proper antibiotics and everything else, but now turns out that the patient, you know, has a local exposure to something else that you didn't know.
01:04:09
Speaker
Let's say the patient is a farmer and, you know, and was working with delivering calves.
01:04:17
Speaker
And maybe the patient has Q fever, you know, coxial pneumonia.
01:04:20
Speaker
So these are things that I want you to think about.
01:04:22
Speaker
Okay, even though everything you're doing is, you know, per the book, everything is well, but the patient is not doing well, maybe the history is going to help you to define that there is another infection that you missed when the patient was diagnosed based on local exposure.
01:04:36
Speaker
The other one is travel exposure, correct?
01:04:38
Speaker
So let's say the patient is, you know, the patient was traveling to some endemic area of like, let's say, tuberculosis, you know, South Africa, South Brazil, India, places that...
01:04:53
Speaker
potentially a patient who acquired tuberculosis traveled back, is back in your country for a few weeks or a few months, and now is developing pneumonia.
01:05:03
Speaker
So it looks like a bacterial pneumonia, but it could be definitely tuberculosis.
01:05:07
Speaker
So travel exposure is going to be important.
01:05:09
Speaker
So revisiting your history is going to be very important.
01:05:12
Speaker
And never forget that one thing that is going to help you to find potential infection reasons for non-responding is pre-existing disease.
01:05:23
Speaker
disease and comorbidities that they are incredibly important to give an example if the patient has a history of cystic fibrosis or or if the patient has history of cpd a lot of times you can already have a very good understanding of what kind of infections this patient especially if you have patients they're going to tell exactly which
01:05:40
Speaker
which infections they had in the past, which infections they're colonized.
01:05:44
Speaker
So they can actually give you a picture that's going to be much more precise than almost anything else because they know their history.
01:05:50
Speaker
Patients that are solid organ transplant patients, patients with cancer and chemotherapy, patients that have a history of treatment for HIV in which the level of the HIV care is going to help if the patient has very low CD4, high CD4, low CD4 is going to be more prone to, let's say, pneumocystis urovechi.
01:06:10
Speaker
So all these things, Sergio, is going to be revisiting the history.
01:06:14
Speaker
And what I always say, if your patient is not responding to your management in the ICU in the first couple of days, three days, you have to go back, revisit the history, because that's going to give you a better understanding if the non-responding is related to the fact that you have another infection, another unexpected infection or not.
01:06:38
Speaker
If you go through this, all this very, you know, very thorough, you know, revisitation of the patient's history and physical, and still you don't pinpoint anything else, at that moment you have to start thinking about non-infectious ideologies.
01:06:53
Speaker
And there are a large number of non-infectious ideologies that mimic
01:06:58
Speaker
pneumonia in the ICU, either CAMP or VAP.
01:07:00
Speaker
And just to give you a little bit of approximation of the rate of this surgery, you know, if you look at most of the studies, you're going to see that in general, 15 to 20 percent of the patients amid the ICU with pneumonia don't have pneumonia, don't have infectious pneumonia, don't have any infectious neurology.
01:07:16
Speaker
So, you know, think about close to one in five patients that you believed
01:07:22
Speaker
that have infectious process-caused pneumonia, they don't.
01:07:26
Speaker
And these are the patients that are not going to respond to your antibiotic therapy or supportive care.
01:07:30
Speaker
They're not going to do well.
01:07:31
Speaker
And these are going to be the ones that are going to be in the non-responding pneumonia group.
01:07:37
Speaker
And one of the things that I always say that is going to be quite fast, easy,
01:07:43
Speaker
and available in most places is just a very plain old CT scan of the chest.
01:07:50
Speaker
You don't need even contrast, you know, even just a very plain CT scan of the chest because right there you can potentially diagnose pulmonary embolism, you can diagnose pulmonary edema, you can diagnose neoplasma, some types of, you know, cancer, metastatic cancer, lung carcinoma.
01:08:06
Speaker
So a lot of things, a chest CT scan alone can help you.
01:08:11
Speaker
to look for non-infectious cause.
01:08:12
Speaker
Also, very important, sometimes by image and by the history, you can diagnose eosinophilic pneumonia, you can diagnose hypersensitivity pneumonia, drug-induced pneumonia, you know, vasculitis.
01:08:27
Speaker
So, let's say if you have a suspicion that this could be
01:08:31
Speaker
sometimes even by CT scan, your suspicion this could be blood, could be some kind of alveolar hemorrhage, you tend to see a little more of this rheumatological disease, antiphospholipid disease, and so forth.
01:08:41
Speaker
Then you're going to be looking for ANCA and some of the vasculitis workup.
01:08:45
Speaker
And vasculitis workup in SU has to be something that you never forget because this could be quite dangerous and life-threatening to our patients as well.
01:08:54
Speaker
So look for, again, rheumatological disease, autoimmune disease, cancer,
01:09:00
Speaker
allergy, drug-induced disease, all these things can mimic pneumonia.
01:09:04
Speaker
And so that has to be seen, Sergio, and it has to be evaluated in parallel with all the other infectious process.
01:09:11
Speaker
So basically, you want to really be very, very extensive in your thinking about infectious and non-infectious process that could lead to non-respondent pneumonia.
01:09:21
Speaker
And on that way, you're going to pinpoint what is the reason for the non-respondent pneumonia and approach that in a much more personalized way.
01:09:31
Speaker
You mentioned earlier, Andre, that the answer in terms of therapeutic conduct for these patients is not to keep throwing antibiotics in terms of having people on prolonged courses or adding a broader spectrum of antibiotics or more powerful antibiotics, but to really rethink what might be the cause.
01:09:54
Speaker
Any other comments you can make on treatment of those patients with non-responding pneumonia?
01:10:02
Speaker
No, I think that the key point here, you know, Sergio, is that if you do not find the reason, the specific reason for why the patient is not responding, you're not going to benefit your patient.
01:10:15
Speaker
You're not going to help your patient.
01:10:16
Speaker
This is not a time for you to start kind of throwing all kinds of different things that you don't know what's happening.
01:10:22
Speaker
Basically, not knowing what's happening is what's going to harm this patient.
01:10:26
Speaker
So your biggest job is...
01:10:28
Speaker
to really find the reason for why the patient is not responding.
01:10:31
Speaker
Otherwise, you're not going to have the proper treatment.
01:10:34
Speaker
And to summarize, the way I see this based on what you share with us is that first fork is infectious versus non-infectious.
Simplified Treatment Approaches
01:10:46
Speaker
Yes.
01:10:46
Speaker
If we think it's non-infectious, then obviously the cause ultimately will dictate the appropriate treatment.
01:10:53
Speaker
So we have to figure it out.
01:10:54
Speaker
And if it's infectious, there's three possibilities.
01:10:57
Speaker
A, the pathogen that is causing the problem is not being covered appropriately.
01:11:03
Speaker
B, I have the appropriate antibiotics, but they're not reaching the lung because I'm underdosing or there's other bioavailability or issues, which obviously we can probably solve with our clinical pharmacist colleagues.
01:11:22
Speaker
Or number three, I have the appropriate antibiotic for the appropriate bug, but there's a source control problem that I have not identified, whether I have an empyema or a septic joint now or something else going on.
01:11:34
Speaker
Would that be a good way of kind of simplifying it in terms of a practical approach?
01:11:39
Speaker
I love surgery.
01:11:40
Speaker
That's perfect.
01:11:41
Speaker
I couldn't say better.
01:11:45
Speaker
So as we close, Andre, just putting everything together for the bedside clinician, could you talk about common pitfalls to avoid in treating pneumonias in the ICU based on what you've seen throughout your years of practice and being consulted on many of these cases?
01:12:02
Speaker
Yeah, I would say, you know, I mean, in a nutshell, Serge, I mean, I would say that a patient
01:12:10
Speaker
you know, your clinical assessment is going to be really the key point for most of these patients, your initial clinical assessment.
01:12:18
Speaker
Do never, never, never rely on a single chest X-ray, never rely on a single, you know, a laboratory marker.
01:12:27
Speaker
You know, a normal chest X-ray does not rule out pneumonia, a normal biomarker in the blood does not rule out pneumonia.
01:12:34
Speaker
So I think that would be
01:12:36
Speaker
the very common pitfalls that I would say that you should avoid because I've seen that so many times.
01:12:41
Speaker
People say, well, you know, I mean, I don't think this patient has pneumonia because the chest X-ray is normal.
01:12:45
Speaker
And then, you know, and then you wait a little bit, you know, and you do another chest X-ray where you do a CT scan and you're going to see like, you know, reprooring progressive pneumonia.
01:12:54
Speaker
So,
01:12:56
Speaker
You know, never, never, never fall into this kind of traps.
01:13:00
Speaker
The same with, you know, the same with the white count, CRP, ProCal, whatever, yes, or whatever you have in your hostel.
01:13:06
Speaker
None of the things are going to roll out in the morning.
01:13:09
Speaker
I would say these are the things that I want you to never forget, that single factors like this will not change anything.
01:13:17
Speaker
the fact that if your pre-test probability, your suspicion is very high based on a history and a physical examination, everything else is going to take second place.
01:13:29
Speaker
That would be my, you know, kind of my, you know, best advice to not miss.
01:13:35
Speaker
Because once you miss this, once you decide to not give the proper antibiotics or supportive care because of one of the things that is misleading you, likely the patient is going to have a worse outcome.
01:13:49
Speaker
Excellent.
01:13:50
Speaker
Any pearl of wisdom you want to add?
01:13:53
Speaker
You know, what I would add is that...
01:13:56
Speaker
you know, in complement of the pitfalls here is that the, you know, nothing ever is going to replace your clinical judgment of putting all these factors
Critical Thinking in Pneumonia Management
01:14:10
Speaker
together.
01:14:10
Speaker
You know, Sergei, I really believe that the best clinician, the best ICU doc, the best ID doc,
01:14:17
Speaker
is the one that put the pieces together.
01:14:20
Speaker
And I'm going to repeat this until the last day of my life.
01:14:24
Speaker
I really think that there's no replacement for critical thinking.
01:14:29
Speaker
There's no replacement for critical analysis and continuous analysis and understanding of what's happened with your patient.
01:14:36
Speaker
You really have to be seeing your patient
01:14:39
Speaker
in a very, very, very close way because there's no other way for you to find out why a patient's improving or not improving from a severe pneumonia, which we already talked is the number one cause of sepsis in every issue in this planet.
01:14:56
Speaker
Andrei, you've been on the podcast before.
01:14:59
Speaker
We like to close with a couple of questions that are unrelated to the clinical topic.
01:15:03
Speaker
Would that be okay?
01:15:05
Speaker
Yes, absolutely.
01:15:06
Speaker
So the last time you were on, we talked about books.
01:15:09
Speaker
Today, I'd like to ask you a little bit about music.
01:15:12
Speaker
If you had to take one or two music albums for a long trip or an extended isolation period, which would they be?
01:15:21
Speaker
Well, I'll tell you.
01:15:22
Speaker
I have so many of them.
01:15:23
Speaker
It's going to be hard to choose.
01:15:26
Speaker
But I'll give you just a couple.
01:15:29
Speaker
I'll just do two or three if you don't mind because it's hard to choose because I almost feel like I...
01:15:34
Speaker
you know, choose among kids, you know, they're all good.
01:15:37
Speaker
They're all good.
01:15:38
Speaker
I don't want to say one is better than John.
01:15:40
Speaker
So I'm going to give, I'm going to give you my first one.
01:15:43
Speaker
I will give you that is I absolutely love.
01:15:45
Speaker
And I, and I've seen him alive twice, uh, is a guitar player called Pat Matheny.
01:15:51
Speaker
Uh, he is, he's originally here from Missouri.
01:15:54
Speaker
He is very close.
01:15:55
Speaker
He, yeah, he started playing in Kansas city.
01:15:58
Speaker
Uh, and, uh,
01:16:00
Speaker
he's nobody knows exactly what he plays and they call them jazz fusion whatever he got many different prides from different styles of music he plays all styles of music but he primarily is an incredible guitar player and very creative his music is just lovely pleasant very intelligent and fun to listen so it's a great combination so there's one album
01:16:29
Speaker
uh then he has many many many albums but there's one album in particular that i i i like to to hear as a way to get myself out of the you know sometimes of the crazy things that we face in life is called we live here we live here it was an album from 1994. the other one that i i have to tell that i cannot get tired of listening and that's based on the fact that i grew up listening to him when i was living in brazil when
01:16:55
Speaker
It's an album from Antonio Carlos Jobim, the father of Bossa Nova.
01:17:01
Speaker
There's an album called Terra Brasilis.
01:17:04
Speaker
Terra, like Earth, Terra Brasilis from 1980.
01:17:06
Speaker
It's a double album, the LPs that I had in the past.
01:17:12
Speaker
I don't have LPs anymore, but I can tell you that it's...
01:17:17
Speaker
The entire album is just so much fun to listen.
01:17:22
Speaker
He's so creative.
01:17:23
Speaker
The music is so beautiful.
01:17:24
Speaker
So Jobin is clearly to me one of the fathers of Brazilian music in modern times.
01:17:33
Speaker
And the third one I want to tell you that goes in the classic world, but I also listen very, very frequently.
01:17:41
Speaker
Gustav Mahler.
01:17:43
Speaker
anything from Gustav Mahler is good, but if somebody wants to get started with Gustav Mahler, I would suggest to start with Symphony No.
01:17:52
Speaker
9.
01:17:53
Speaker
There's an album from the Chicago Symphony, and I think the maestro is Claudia Bado.
01:18:00
Speaker
There's one album that's specifically from the Chicago Symphony that has the Mahler No.
01:18:04
Speaker
9.
01:18:04
Speaker
It's just...
01:18:06
Speaker
You don't need to know anything about classical music.
01:18:08
Speaker
You listen to that music and you fall in love.
01:18:10
Speaker
I mean, he is just an incredible composer.
01:18:12
Speaker
So I'll stop here.
01:18:14
Speaker
Otherwise, we're going to be talking for another hour, Sergio.
01:18:16
Speaker
Well, I think it's a beautiful list.
01:18:19
Speaker
And I obviously am familiar with some of it.
01:18:21
Speaker
But I can't say I'm a Pathmethodi expert.
01:18:24
Speaker
But I have some of his albums.
01:18:26
Speaker
And Carlos Jobim, of course, is an icon, a bossa noba in music in general.
01:18:32
Speaker
But what I would say, Andre, very appropriate for our conversation because this is a very broad spectrum approach.
01:18:40
Speaker
So I think it's perfect.
01:18:44
Speaker
That's funny.
01:18:47
Speaker
So the second question is if you could share something you have changed your mind about in the recent years.
01:18:55
Speaker
Yeah.
01:18:55
Speaker
So, you know, Sergio, the question,
01:19:01
Speaker
I would say that, I mean, it was an evolving process is that, and I believe that when I really, when I have that, you know, that kind of,
01:19:13
Speaker
strong diagnostic, you know, feeling that the patient has a, you know, severe pneumonia, either severe CAP or VAP.
01:19:25
Speaker
I learned through the years that it make a difference to really be aggressive and start antibiotics, not kind of lingering around to see what's going to happen in somebody that that ill, not only timing, but dosing.
01:19:39
Speaker
The two things that I adapt and I change through the years are,
01:19:42
Speaker
I'm much more aggressive about starting antibiotics in these patients, and I'm much more aggressive about using prolonged infusions.
01:19:50
Speaker
We use a lot of continuous infusions, but I've used that for years, and I felt impressively happy.
01:19:58
Speaker
With the paper that was the Blink 3, that was the RCT just published in Gemma recently, there was this Australian multinational trial showing that actually, you know, in, I think it was over 100 different ICUs in the world.
01:20:11
Speaker
I mean, impressive, 7,000 patients.
01:20:12
Speaker
I mean...
01:20:15
Speaker
I think in our lifetime, we're not going to see another RCT that well done.
01:20:20
Speaker
And unquestionably, the use of beta-lactam, extended infusion beta-lactam, meaning that you're going to use for something in a range of three hours or so, three to four hours every dose, that means when you give the beta-lactam to patients with, in this case, with sepsis, but again, as I told you, most of these patients, sepsis are going to have pneumonia or inter-abdominal infections.
01:20:41
Speaker
They had a better survival process.
01:20:43
Speaker
when they use that, because especially with the beta-lactamins, you can, you know, you can, the longer you are above the MIC, the more effective is the drug.
01:20:51
Speaker
So, so I, I, you know, through the years, I learned that the 30 minutes infusion that we grew up doing the ICUs are not really that good anymore.
01:21:00
Speaker
And, and again, sure, you know, you need an infusion pump, you need a nurse that knows what to do with this.
01:21:06
Speaker
So if you don't have this, you better give the 30 minute infusion.
01:21:09
Speaker
But if you have, you
01:21:10
Speaker
the minimal infrastructure lab to do this, I learned through the years that timing of initiation of antibiotics and dosing of antibiotics are absolutely critical to save lives.
01:21:24
Speaker
And I evolved to be much better with this today, Sergio.
01:21:30
Speaker
Excellent.
01:21:31
Speaker
Finally, to close, is there any closing thought, quote, or thought that you want to share with our audience?
01:21:40
Speaker
So, you know, what I would say is, Sergio, that, you know, all of us that deal with critically opatients, and when it comes to infection, I want you to always remember that different from, you know, cardiac disease and, you know, and disease that have a much more physiological approach, you know, when it comes to acute infection, you know,
01:22:05
Speaker
It is a critical illness that is nonlinear.
01:22:09
Speaker
I know it sounds a little nerdy and a little bit nuanced, but it's really important.
01:22:14
Speaker
Because when you have an acute illness, let's say a heart failure or myocardial infarction, you know exactly the point.
01:22:21
Speaker
Okay, when are you going to give thrombolytics?
01:22:23
Speaker
What's happening?
01:22:23
Speaker
Have you had the AQG?
01:22:24
Speaker
Everything follows a linear pattern in the ICU.
01:22:29
Speaker
When it comes to infection, nothing is linear.
01:22:33
Speaker
That's what we call complex biology or nonlinear biology.
01:22:36
Speaker
And why this is important?
01:22:38
Speaker
This is important because there will not be any replacement for the ICU doc to use critical thinking in order to really make the best decision for these patients with acute infections.
01:22:52
Speaker
So I think my last message that every intensive is should know is that your clinical experience, your critical thinking, your bedside judgment is going to be more important than ever to treat acute infections, especially in this complex world where we are seeing.
01:23:11
Speaker
new infections and infections and more patients with different host response, different immunosuppressive drugs, your critical thinking is going to be more important than ever.
01:23:21
Speaker
So never, never undervalue your skills and the importance of your skills to save patients in the ICU.
01:23:30
Speaker
This is never going to change.
01:23:32
Speaker
And I truly believe that this is the best asset we have in the ICU today.
01:23:37
Speaker
I think this is a perfect place to stop.
01:23:39
Speaker
Andre, thank you so much for your generosity with your time and sharing your expertise.
01:23:45
Speaker
Always a great conversation, a lot to learn from.
01:23:49
Speaker
And we'll link a lot of the articles that we discussed in the show notes.
01:23:54
Speaker
It would encourage our listeners to look them up and also a link to all those wonderful albums and music that you recommended.
01:24:03
Speaker
So look forward to having you back soon.
01:24:06
Speaker
And until then, be well.
01:24:09
Speaker
Thank you so much, Serge.
01:24:10
Speaker
I'll be always glad to be back.
01:24:12
Speaker
Have a great day.
01:24:14
Speaker
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01:24:17
Speaker
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01:24:23
Speaker
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01:24:28
Speaker
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