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Chinese Guidelines for the Diagnosis and Treatment of Hospital- Acquired Pneumonia and Ventilator-Associated Pneumonia in Adults (2018 Edition)

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Chinese Guidelines for the Diagnosis and Treatment of Hospital- Acquired Pneumonia and Ventilator-Associated Pneumonia in Adults (2018 Edition) 2616 Guideline Chinese guidelines for the diagnosis and treatment of hospital- acquired pneumonia and ventilator-associated pneumonia in adults (2018 Edition) Yi Shi1#, Yi Huang2#, Tian-Tuo Zhang3#, Bin Cao4#, Hui Wang5#, Chao Zhuo6#, Feng Ye6#, Xin Su1#, Hong Fan7#, Jin-Fu Xu8#, Jing Zhang9#, Guo-Xiang Lai10#, Dan-Yang She11#, Xiang-Yan Zhang12, Bei He13, Li-Xian He9, You-Ning Liu14, Jie-Ming Qu15; on behalf of Infection Study Group of Chinese Thoracic Society, Chinese Medical Association 1Department of Pulmonary and Critical Care Medicine, Nanjing Jinling Hospital, Nanjing University, School of Medicine, Nanjing 210002, China; 2Department of Pulmonary and Critical Care Medicine, Shanghai Changhai hospital, Navy Medical University, Shanghai 200433, China; 3Department of Pulmonary and Critical Care Medicine, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, China; 4Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Capital Medical University, Beijing 100029, China; 5Department of Clinical Laboratory Medicine, Peking University People’s Hospital, Beijing 100044, China; 6State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou 510120, China; 7Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; 8Department of Pulmonary and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China; 9Department of Pulmonary Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai 200032, China; 10Department of Pulmonary and Critical Care Medicine, Dongfang Hospital, Xiamen University, Fuzhou 350025, China; 11Department of Pulmonary and Critical Care Medicine, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China; 12Department of Pulmonary and Critical Care Medicine, Guizhou Provincial People’s Hospital, Guizhou 550002, China; 13Department of Respiratory Medicine, Peking University Third Hospital, Beijing 100191, China; 14Department of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China; 15Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China #The authors are listed in the order by which their contribution section appears in this expert consensus document and are listed as co-first authors. Correspondence to: Jie-Ming Qu, MD. Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China. Email: [email protected]. Submitted Feb 25, 2019. Accepted for publication May 19, 2019. doi: 10.21037/jtd.2019.06.09 View this article at: http://dx.doi.org/10.21037/jtd.2019.06.09 Hospital-acquired pneumonia (HAP) and ventilator- the accumulating evidence from the researches in China, associated pneumonia (VAP) are the most common hospital- which shows that the distribution and antibiotic resistance acquired infections in China. The difficulty in diagnosis rate of HAP/VAP pathogens in China are largely different and treatment of HAP/VAP leads to high mortality. In from the data reported in other countries. Therefore, it is China, it has been nearly two decades since the initial necessary to amend the initial guideline in 1999 accordingly “Guideline for the Diagnosis and Treatment of Hospital-acquired in order to better guide clinical practice. Pneumonia (draft)” was published in 1999 (1). Afterwards, The initial HAP guideline was updated by the Infection a number of guidelines for HAP/VAP have been published Study Group of Chinese Thoracic Society, Chinese Medical or updated at home and abroad (2-10). The definitions of Association (CMA). The overall framework and main HAP/VAP have been changing as more and more relevant contents of the updated HAP/VAP guideline were finalized researches available highlighting greater details. Moreover, after multiple rounds of face-to-face workshops. After there are growing evidence in the epidemiology, etiology, repeated discussions among all the members of the Infection clinical diagnosis and treatment of HAP/VAP, especially Study Group and extensive consultations from domestic and © Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2019;11(6):2581-2616 | http://dx.doi.org/10.21037/jtd.2019.06.09 2582 Shi et al. 2018 China CAP guideline for adults Table 1 Evidence level and grade of recommendation Evidence level and grade of Description recommendation Evidence level Level I (high) Evidence from well-designed, randomized, controlled trials (RCTs), authoritative guidelines, and high quality systematic reviews and meta-analyses Level II (moderate) Evidence from RCTs with some limitations (e.g., trials without allocation concealment, nonblinded, or loss to follow-up not reported), cohort studies, case series, and case-control studies Level III (low) Evidence from case reports, expert opinions and in vitro antimicrobial susceptibility studies without clinical data Grade of recommendation A (strong) Most patients, physicians, and policy makers will adopt the recommended action B (moderate) The recommendation will be adopted by the majority, but not by some individuals. Decisions should be made with consideration of the specific condition of the patient to reflect his/her values and willingness C (weak) Insufficient evidence; decisions must be made via mutual discussions involving the patients, physicians, and policy makers foreign experts in related fields, the draft was revised several of hospital admission and occurring 48 hours or more after times. Finally, the consensus was reached on the basis of admission in patients not receiving invasive mechanical evidence-based medicine. The level of evidence and grading ventilation during hospitalization. VAP is defined as a of recommendation are defined the same way as in “Diagnosis pneumonia occurring >48 hours after endotracheal intubation and treatment of community-acquired pneumonia in adults: or tracheotomy to receive mechanical ventilation. A 2016 clinical practice guidelines by the Chinese Thoracic Society, pneumonia occurring within 48 h after removing mechanical Chinese Medical Association (2016 Edition)” (11). The grading ventilation and extubation is also considered as VAP (2,3). system classifies recommendations according to the balance At early times, HAP was defined as any parenchymal of the benefits and downsides (harms, burden, and cost) on lung infection occurring in hospital due to the pathogens the basis of the quality of evidence. The quality of evidence existing in the hospital environment. In the Chinese reflects the confidence in estimates of the true effects of “Guideline for the Diagnosis and Treatment of Hospital-acquired an intervention (Table 1). In general, the higher the quality Pneumonia (draft)” published in 1999, the definition of of evidence is, the stronger the grade of recommendation. HAP covered the pneumonia occurring after establishing However, they do not fully correspond to each other. The artificial airway and mechanical ventilation (1). There source of evidence, willingness and values of patients, as are various confounding factors in the numerous HAP well as resource consumption should also be considered clinical studies previously conducted at home and abroad, when making a recommendation. We emphasize that under including some patients undergoing mechanical ventilation. the premise of the same level of evidence, the evidence and However, it is generally agreed that VAP is a special type research results in China should be adopted preferentially. of HAP. Considering the significant difference between This guideline applies to the immunocompetent HAP/ HAP and VAP in terms of clinical features, empiric VAP patients aged 18 years or older. The main body of treatment, and prevention strategy, the Guidelines for this document is composed of 8 sections and 1 annex. It the management of adults with hospital-acquired, ventilator- is expected that the revision and popularization of this associated, and healthcare-associated pneumonia issued by the HAP/VAP guideline will further standardize the diagnosis and Infectious Diseases Society of America/American Thoracic treatment of HAP/VAP in China. Society (IDSA/ATS) in 2005 (2005 IDSA/ATS HAP/VAP guideline) have classified HAP into HAP in narrow sense and VAP (2). The evidence in recent years further confirms Definitions that HAP is considerably different from VAP in empiric HAP is defined as a pneumonia not incubating at the time treatment and clinical prognosis. The updated IDSA/ATS © Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2019;11(6):2581-2616 | http://dx.doi.org/10.21037/jtd.2019.06.09 Journal of Thoracic Disease, Vol 11, No 6 June 2019 2583 HAP/VAP guideline in 2016 specifically emphasizes that 15.3% in RICU and 0.9% in general wards. The all-cause HAP only refers to the pneumonia occurring after hospital mortality of HAP is 22.3% and 34.5% for VAP. HAP is admission in the patients without endotracheal intubation associated with 23.8±20.5 days of hospital stay on average, and not associated with mechanical ventilation, while VAP 10 days longer than that of non-HAP patients.
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