HAP, VAP and non-resolving PNAs Flashcards
Which PNA?
48+ hours after admission and did not appear to be incubating at the time of admission
Hospital Acquired Pneumonia (HAP)
(Nosocomial)
Which PNA?
a type of HAP that develops more than 48 – 72 hours after endotracheal intubation
Ventialator associated pneumonia (VAP)
Pathophys of what?
•Pharyngeal colonization
- Upper airway instrumentation (NG or ET tubes)
- Contamination by dirty hands, equipment and contaminated aerosols
- Tx with broad spectrum antibiotics
- Malnutrition, advanced age, altered LOC, swallowing disorders, underlying pulmonary and systemic disease
VAP
What are common Aerobic gram-neg bacilli that cause HAP/VAP
- E-coli
- Klebsiella pneumonia
- Enterobacter spp
- Pseudomonas aeruginosa
- Acinetobacter
“EEK PA”- don’t be negative!
What are common gram positive cocci that cause HAP/VAP
Staph aureus (including MRSA)
Stretococcus spp
What 6 things are needed to dx HAP/VAP
- New lung infiltrate plus evidence that the infiltrate is of infectious origin (F, purulen sputum, leukocytosis, decline in oxygenation)
- Sputum gram stain and culture are indicated
- blood cultures
- CBC/CMP
- pulse oximety and or ABGs
- consider thoracentesis
General guidelines for tx of which PNAs?
- Consider local microbiology and antimicrobial susceptibility patterns
- Consider risk factors for multidrug-resistant pathogens
- Inappropriate therapy is major risk of excess mortality
- Initial antibiotic therapy should be given promptly
- Use different antibiotic class for patients with recent antibiotic use
- Prevention!
Tx of HAP/VAP
HAP/VAP- What are 6 risk factors for multi-drug resistent pathogens?
- Antimicrobial therapy in previous 90 days
- Current hospitalization ≥ 5 days
- Admission from healthcare-related facility
- High frequency of antibiotic resistance in community or specific hospital unit
- Immunosuppressive disease and/or therapy
- Risk factors for healthcare-associated pneumonia
THe following are risk factors for what?
- hospitalization ≥ 2 days in previous 90 days
- home infusion therapy (including antibiotics) or home wound care
- chronic dialysis within 30 days
- family member with MDR infection
- residence in nursing home or extended care facility
HAP/VAP:
Risk factors for multi-drug resistent pathogens
What is the duration of tx of HAP, VAP?
- Traditional length of treatment: 14-21 days
- Patients who respond to initial treatment may limit treatment to 7 days
•Exception: Pseudomonas aeruginosa (have to tx for 14 days)
Best tx of VAP is prevention… What 6 things can be done to prevent this?
- Avoidance of acid-blocking meds
- Decontamination of oropharynx
- Selective decontamination of the gut
- Probiotics
- Positioning (to decrease risk of aspiration)
- Subglottic drainage
What other 5 diagnoses should you consider in non-resolving pneumonias?
- Atypical Infection
- Viral
- Fungal
- Aspiration
- CHF
- Cancer
- Fibrosis
What 4 diagnostic tests could be done to further evaluate a non-resolving pneumonia?
–Chest CT
–Fiberoptic bronchoscopy
–Thoracoscopy
–Open lung biopsy
What is a common cause of CAP and something that you should consider in a non-resolving pneumonia?
Influenza (A, B, C subtypes)
Check flu A, B antibodies
***Secondary bacterial pneumonia COMMON (STAPH)
What are the 4 types of fungal pneumonias
- Histoplasmosis
- Blastomycosis
- Coccidiodomycosis
- Pneumocystis jirovecii pneumoni (HIV related)
Clinical presentation of what?
–Fever, cough, dyspnea
–Fatigue, chills, chest pain, weight loss
–Tachypnea, crackles, rhonchi, often co-infected with oral thrush
Pneumocystis pneumonia
What is the most common opportunistic infection in patients with AIDS
Pneumocystis pneumonia (caused by Pneumocystis jirovecii)
What is Pneumocystis pneumonia caused by?
Pneumocystis jirovecii
(an atypical fungal infection)
What are 5 risk factors of Pneumocystis pneumonia?
- prior PCP episode
- oral thrush
- recurrent bacterial pneumonia
- unintentional weight loss
- high plasma HIV RNA level
The following are labs/diagnostics for which PNA?
–Hypoxia
–Elevated LDH level
–CXR: diffuse, bilateral, interstitial or alveolar infiltrates
Pneumocystis pneumonia
How is pneumocystis pneumonia treated?
- Trimethoprim-sulfamethaxazole ‘TMP-SMX’ (Bactrim) x 21 days
- +/- corticosteroids based on severity
- Anti-retroviral therapy (ART)
When do you prophylactically tx for pneumocystis pneumonia and what do you tx w/?
Prophylaxis w/ TMP-SMX
- CD4 count < 200 (or percentage < 14%)
- Oropharyngeal candidiasis
- CD4 count of 200-250, when frequent monitoring not possible
Which pneumonia?
•Displacement of gastric contents to the lung causing injury and infection
Aspiration pneumonia
What is the microbiology of aspiration pneumonia
Microbiology: Gram negative and anaerobic pathogens
What are 5 risk factors for Aspiration PNA?
- Altered level of consciousness
- Drug/alcohol use
- Seizures
- General anesthesia (post-op)
- CNS disease (CVA, Parkinson’s, ALS, sedation)
- Impaired swallowing (esophageal disease)
- Tracheal or NG tube
- Anatomical defect/abnormality
Presentation of which PNA?
–Constitutional symptoms
–Cough w/ foul smelling purulent
–Often, poor dentition
Aspiration pneumonia
Diagnostics of which PNA?
–Culture only from transthoracic aspiration, thoracentesis or bronchoscopy
–CXR: RLL infiltrate common; cavitary consolidation, air-fluid level
Aspiration pneumonia
How is aspiration pneumonia treated?
- supportive care
-
antibiotics:
- Clindamycin or Amoxicillin-clavulanate
- penicillin + metronidazole
