HAP (Exam 2 Cut Off) Flashcards
HAP
- Hospital Acquired Pneumonia
- Most commonly acquired hospital based infection
- Not incubating at time of admission and occurring >= 48 hours after admission
- Increases hospital stay by 7-9 days/patients
- Serious complications occur in ~50% of patients
- Incidence increases with age
VAP
- Ventilator associated pneumonia
- Pneumonia that arises >48 hours after endotracheal intubation
- Occurs in ~10% of intubated patients
- Highest chances in first 5 days
- Increases hospitalization, mechanical ventilation, cost, mortality
Pneumonia
- Presence of new lung infiltrate plus clinical evidence that infiltrate is infectious
- New onset of fever, purulent sputum, leukocytosis and decline in oxygenation
Pathogenesis
- Microaspiration may occur in up to 45% during sleep
- Oropharynx of hospitalized patients colonized with GNR in 35-75% of patients
- Invade lower respiratory tract via aspiration, inhalation of contaminated aerosols, or hematogenous spread (rare)
Risk Factors + Preventative Measures
- Intubation => less invasive intubation
- Reintubation => avoidance, careful extubation
- Nasotracheal intubation => prefer oral intubation
- Supine body position => semi-recumbent body position
- Pharmacologic paralysis => avoiding muscle relaxant
- Daily change of circuits => changed weekly
Diagnostic Methods
- Clinical observation
- Chest x-rays
- Blood culture (+ in 15%)
- Non-invasive: endotracheal aspiration, spontaneous expectoration, sputum induction, nasotracheal suctioning
- Invasive methods: BAL, protected specimen brush
- Procalcitonin (PCT), CRP tests
Antimicrobial Therapy
- Treat empirically first
- Empiric therapy guided by severity of pneumonia, time of onset, specific risk factors
- Adapted to local microbial resistance pattern
Empiric Pneumonia Therapy should cover…
- S. aureus - MSSA or MRSA
- P. aeruginosa - monotherapy vs combo therapy
MDR VAP Risk Factors
- Prior IV antibiotics use within 90 days
- Septic shock at time of VAP
- ARDS preceding VAP
- Five or more days of hospitalization prior to the occurrence of VAP
- Acute renal replacement therapy prior to VAP
VAP Empiric Therapy
-Vanco 15 mg/kg IV q8-12 hours (trouch 15-20 mg/L)
OR
-Linezolid 600 mg PO/IV q12h
MRSA coverage needed if….
- Patients with risk for MDR
- Patients in units with >10-20% S. aureus are MRSA
- Patients in units where MRSA rates are unknown
Cover pseudomonas coverage with 2 agents when….
- Patients at risk for MDR
- Patients in unit with >10% of Gram “-“ isolates are resistant to an agent being considered for monotherapy
- Patients in ICU where resistance rates are unknown
Combo Therapy for Risk for MDR
First: Antipseudomonal cephalosporin OR Antipseudomonal carbapenem (ESBL + present) OR B-lactam/B-lactamase inhibitor
+
Second: Antipseudomonal fluoroquinolone OR Aminoglycoside
+
Third: Linezolid OR Vanco (MRSA risk)
Drugs in Class Examples
- Antipseudomonal cephalosporin: cefepime, ceftazidime
- Antipseudomonal carbapenem: imipenem, meropenem
- Antipseudomonal fluoroquinolone: cipro, levo
HAP + Mortality Risk Factors
- Need for ventilator support due to pneumonia
- Septic shock
HAP + Risk for MRSA
- IV abx in prior 90 days
- Treatment in units with unknown resistance rates or >20% MRSA prevalence
HAP + Double coverage for pseudomonas
- IV abx in prior 90 days
- High risk for mortality
- Structural lung disease increasing risk for Gram “-“ infection: cystic fibrosis, bronchiectasis
- Once susceptibility is known, can use one agent monotherapy (NOT AMG) unless patient is still in septic shock or at high risk of death
Blood Cultures + Drug Preferences
- MRSA: Vanco or linezolid alone (D/C all others)
- MSSA: nafcillin or cefazolin (D/C others)
- P. aeruginosa: monotherapy as long as no current shock, risk of death, and susceptibility is available
- Adjust treatment based on susceptibility results and if monotherapy is appropriate for all other pathogens
Durations of Therapy
VAP and HAP: 7 days
