HAP and VAP

Question 1

What is the definition of HAP?

Answer 1

pneumonia that occurs 48 hours or more after admission, which was not incubating at the time of admission, in a non ventilated patient

Question 2

What is VAP?

Answer 2

pneumonia that arises more than 48- 72 hours after endotracheal intubation

Question 3

What are the signs in VAP?

Answer 3

Radiology signs (2 or more serial CXR with at least one of the following

1. new or progressive and persistent infiltrate
2. consolidation
3. cavitation

Clinical signs part 1 (at least 1) AND

1. fever (temperature > 38 deg with no recognised cause)
2. leukocytosis > 12 000WCC/uL or leukopenia <4000 WCC/ uL
3. AMS in adults > 70 yrs with no other cause

Clinical signs part 2 (at least 2)

1. new onset of purulent sputum/ changes in character of sputum/ increased respiratory secretion/ increased suctioning requirements
2. new onset worsening cough/ dypsnea/ tachypnea
3. rales or bronchial breath sounds
4. worsening gas exchange

microbiological criteria

1. positive growth in blood culture not related to another source of infection
2. positive growth in culture of pleural fluid
3. positive quantitative culture from BAL
4. > 5% cells with intraceullar bacteria on direct microscopic examination of gram stained BAL
5. histopathological evidence of pneumonia

Question 4

How to prevent VAP?

Answer 4

• Elevation of head of bed
• Daily sedation vacations and assessment of readiness to extubate
• Daily oral decontamination w chlorhexidine
• Subglottic suctioning
• PUD and DVT prophylaxis: not definitively linked to directly to VAP, but are known Cx of ventilated pts w acute respiratory failure
• Note: early tracheotomy has not been proven to decrease VAP

Question 5

How to manage HAP/ VAP?

Answer 5

High mortality: MRSA cover + 2 anti-pseudomonal agents of different classes

Low mortality

• High risk of pseudo: 2 anti-pseudomonal agents, 1 of which has activity against MSSA (if MRSA not covered) (e.g. pip/tazo + gentamicin)
• Low risk of pseudo: 1 anti-pseudomonal agent which has activity against MSSA (if MRSA not covered) (e.g. pip/tazo)
• • MRSA cover if risk of MRSA (+ vancomycin, or linezolid)