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

Background The French Society of Anaesthesia and Intensive Care Medicine and the French Society of Intensive Care edited guidelines focused on hospital-acquired pneumonia (HAP) in intensive care unit. The goal of 16 French-speaking experts was to produce a framework enabling an easier decision-making process for intensivists. Results The guidelines were related to 3 specific areas related to HAP (prevention, diagnosis and treatment) in 4 identified patient populations (COPD, neutropenia, post-operative and paediatric). The literature analysis and the formulation of the guidelines were conducted according to the Grade of Recommendation Assessment, Development and Evaluation methodology. An extensive literature research over the last 10 years was conducted based on publications indexed in PubMed™ and Cochrane™ databases. Conclusions HAP should be prevented by a standardised multimodal approach and the use of selective digestive decontamination in units where multidrug-resistant bacteria prevalence was below 20%. Diagnosis relies on clinical assessment and microbiological findings. Monotherapy, in the absence of risk factors for multidrug-resistant bacteria, non-fermenting Gram-negative bacilli and/or increased mortality (septic shock, organ failure), is strongly recommended. After microbiological documentation, it is recommended to reduce the spectrum and to prefer monotherapy for the antibiotic therapy of HAP, including for non-fermenting Gram-negative bacilli.


Introduction
Hospital-acquired pneumonia (HAP) is the most common infection in the intensive care unit (ICU) [1]. In the ICU, HAP is associated with a mortality rate of 20% and with increased duration of mechanical ventilation and ICU and hospital length-of-stay [2,3]. The criteria to diagnose pneumonia are shown in Table 1 (Fig. 1).

Method
Sixteen French-speaking experts produce guidelines in three specific areas related to HAP: prevention, diagnosis and treatment as well as the specificities pertaining to different identified patient populations (COPD, neutropenia, post-operative and paediatric). The schedule of the group was defined upstream (Table 2) (Fig. 2).
The questions were formulated according to the PICO (Patient, Intervention, Comparison, Outcome) format. The formulation of the guidelines was conducted according to the GRADE methodology (Grade of Recommendation Assessment, Development and Evaluation) [4,5]. In the absence of supporting literature, a question could be addressed by a recommendation under the form of an expert opinion ("the experts suggest that…") ( Fig. 3).

Open Access
*Correspondence: Marc.LEONE@ap-hm.fr 1 Service d' Anesthésie et de Réanimation, Aix-Marseille Universite Hopital Nord, chemin des Bourrely, 13015 Marseille, France Full list of author information is available at the end of the article These guidelines with their arguments were published in the journal Anaesthesia Critical Care and Pain Medicine [6] (Fig. 4).
First area, PREVENTION Which HAP prevention approaches decrease morbidity and mortality in ICU patients?
R1. 1 We recommend using a standardised multimodal HAP prevention approach in order to decrease ICU patient morbidity (Grade 1+). R1.1 Paediatrics We suggest using a standardised multimodal approach aiming at preventing HAP in order to decrease paediatric ICU patient morbidity (Grade 2+).
R1.2 In units where multidrug-resistant bacteria prevalence is low (< 20%), we suggest applying routine selective digestive decontamination using a topical antiseptic administered enterally and a maximal 5-day course of systemic prophylactic antibiotic to decrease mortality (Grade 2+). R1.3 Within a standardised multimodal HAP prevention approach, we suggest combining some of the following methods to decrease ICU patient morbidity: • Promote the use of non-invasive ventilation to avoid tracheal intubation (mainly in post-operative digestive surgery patients and in patients with COPD), • Favour orotracheal over nasotracheal intubation when required

3-Associate some of the following methods (1 st line):
-Favour the use of NIV to prevent intubation -Limit dose and duration of sedatives and analgesics associated with mechanical ventilation -Initiate early enteral feeding -Regularly verify endotracheal tube cuff pressures -Perform sub-glottic suction (/6-8 hours) using an appropriate endotracheal tube -Favour the orotracheal route for intubation NB: The associaƟon of head of bed elevaƟon <30 and/or oro-pharyngeal decontaminaƟon with 0.12 or 0.2% chlorhexidine could be proposed in associaƟon to these measures, despite low efficiency, because they do not cost much and are well tolerated.

4-Avoid using the following methods:
-Systematic early tracheotomy (apart from specific indications) -Antiulcer prophylaxis (apart from specific indications) -Post-pyloric enteral feeding (apart from specific indications) -Probiotics -Systematic early changing of humidifier filters (apart from a recommendation from the manufacturer) -Closed endo-tracheal suction systems - The use of intubation tubes lined/coated or incorporating silver or antiseptics, or with an "optimised" cuff shape -Oro-pharyngeal decontamination using povidone-iodine -Prophylactic nebulised antibiotics -Daily skin decontamination using antiseptics  Doses are given for informaƟon purposes only in paƟents with normal renal funcƟon and standard weight; b Favour the use of aminoglycosides over fluoroquinolones to limit emergence of MDR bacteria; c According to the guidelines' criteria « Reduce de use of anƟbioƟcs in intensive care unit» ; d Favour the use of amikacin over gentamicin due to enhanced efficacy against non-fermenƟng Gram-negaƟve bacilli. *Risk factors for non-fermenƟng Gram-negaƟve bacilli: anƟbioƟc therapy in the previous 90 days, prior hospital stay of more than 5 days, renal replacement therapy requirement during pneumonia, sepƟc shock, acute respiratory distress syndrome. **Methicillin-resistant Staphylococcus aureus (MRSA) risk factors: high local prevalence of MRSA, recent colonisaƟon by MRSA, chronic skin lesions, chronic renal replacement therapy.

Fig. 4 Treatment options (expert opinion)
• Limit dose and duration of sedatives and analgesics (promote their use guided by sedation/pain/ agitation scales, and/or daily interruptions), • Initiate early enteral feeding (within the first 48 h of ICU admission), • Regularly verify endotracheal tube cuff pressure, • Perform sub-glottic suction (every 6 to 8 h) using an appropriate endotracheal tube (Grade 2+).
R1.4 Within a standardised multimodal HAP prevention approach, we suggest not using the following methods to decrease ICU patient morbidity: • Systematic early (< day 7) tracheotomy (except for specific indications), • Anti-ulcer prophylaxis (except for specific indications), • Post-pyloric enteral feeding (except for specific indications), • Administration of probiotics and/or synbiotics, • Early systematic change of the humidifier filter (except for specific manufacturer recommendations) • Use of closed suctioning systems for endotracheal secretions, • Use of antiseptic-coated intubation tubes or with tubes an "optimised" cuff shape, • Selective oropharyngeal decontamination (SOD) with povidone-iodine, • Use of prophylactic nebulised antibiotics, • Daily skin decontamination using antiseptics (Grade 2−).
R1.5 In weaning of COPD patients from ventilation, we suggest using non-invasive ventilation to reduce length of invasive mechanical ventilation, incidence of HAP, morbidity and mortality (Grade 2+).

Second area, DIAGNOSIS
What methods to diagnose HAP should be used to decrease ICU patient morbidity and mortality?
R2. 1 We suggest not using the clinical scores (CPIS, modified CPIS) for diagnosing HAP (Grade 2−). R2. 2 We suggest collecting microbiological airway samples, regardless of type, before initiation of any change in antibiotic therapy (Grade 2+).

R2.2 Paediatrics
We suggest collecting microbiological airway samples, regardless of type, before initiation of any change in antibiotic therapy (Grade 2+).
R2. 3 We suggest not measuring plasma or alveolar levels of procalcitonin or soluble TREM-1 to diagnose HAP (Grade 2−).
Third area, TREATMENT What therapeutic options for HAP should be used to decrease ICU patient morbidity and mortality?