HAP/VAP (nosocomial) Flashcards
what are the risk factors of HAP/VAP?
patient related factors - elderly - smoking - COPD - cancer, immunosup - prolonged hospitalisation - coma, impaired consciousness - malnutrition infection control related factors - hand hygiene compliance - contaminated resp care device healthcare related factors - prior ab use - sedative - opioid analgesics - mech ventilation - supine position (easier to choke on secretion when lying down)
what are some prevention strategies for HAP/VAP?
- practice consistent hand hygiene
- judicious use of ab and med with sedative effect
what are some prevention strategies for VAP specifically?
- limit duration of mech ventilation
- minimise duration and deep level of sedation
- elevate head of bed by 30 deg (min risk of aspirating oro-pharyngeal secretion)
what org to cover for HAP/VAP?
gram pos - strep pneumo - s aureus gram neg - h flu - prteus spp - e coli - enterobacter spp - klebsiella pneumo (MRSA) - ps aeruginosa (MRSA)
more gram neg, esp MRSA gram nef
what is the empiric coverage?
MINIMUM
- cover S aureus MSSA and Ps aeruginosa MRSA
may need additional cove for
- MDRO risk factors
- mortality risk factors
- hospital or unit bacteria susceptibiity rate (use antibiogram)
what are the MDRO risk factors for HAP? (1)
- prior IV ab within 90 days
what are the MDRO risk factors for VAP? (5)
- prior iv ab within 90 days
- septic shock (hypotension caused by infection, req vasoactive med) at the time of VAP onset
- acute resp distress syndrome preceding VAP onset
- > 5 days of hospitalisation prior to VAP onset
- acute renal replacement therapy prior to VAP1
wat are teh mortality risk factors for HAP? (2)
- req mech ventilation as a result of HAP
- in septic shock
what ab covers both MSSA and pseudomonas? (4)
- cefepime
- meropenem
- pip/tazo
- levofloxacin
what is the purpose of an antibiogram
to guide empiric therapy selection
tells you how resistant the org is in the hospital
what is the backbone regimen for HAP? empiric tx
- anti-pseudomonal beta lactam (piptazo or cefepime or meropenem or imipenem)
OR - antipseudomonal FQ (levofloxacin)
what org to cover for backbone regimen?
- strep pneumo
- s aureus mssa
- pseudonomas aeruginosa
- ab sensitive enterobacteraceae eg. e coli, proteus spp, enterobacterspp.
who needs empiric MRSA coverage?
- MDRO risk factors
- mortality risk fac
- MRSA prevalance >20% or unknown
if indicated, what ab to add to backbone regimen for MRSA cov for HAP?
- vancomycin
- linezolid
(NOT daptomycin even tho it covers for MRSA coz it get sinactivated in the lungs)
who needs additional gram neg cov in HAP?
- MDRO risk fac
- mortality risk fac
if indicated, what ab to add to backbone regimen for additional gram neg cov for HAP?
- gentamicin
- amikacin
- tobramycin
- ciproflaox
- levoflox
- choose 2 drugs from diff class- coz there could be cross resistance from drugs in same class
what is the backbone empiric tx for VAP?
- anti pseudomonal beta lactam (piptazo or cefepime or meropenem or imipenem)
OR - antipseudomonal FQ (levofloxacin)
who needs empiric MRSA coverage for VAP?
- MDRO risk factors
- MRSA prevalence >10-20% or unknown
if indicated, what ab to add to backbone regimen for MRSA cov for VAP?
- vancomycin
- linezolid
who needs additional gram neg cov in VAP?
- MDRO risk fac
- single anti pseudomonal agent with activity <90% or unknown
if indicated, what ab to add to backbone regimen for additional gram neg cov for VAP?
- gentamicin
- amikacin
- tobramycin
- levoflox
ciprioflox
what are teh benefits of additional gram neg cov (give 2 drugs that cover gram neg)?
- synergistic actiity
- prevent resistance
- expand spectrum of cov
what are the potential risks of additional gram neg cov
- higher cost
- more adverse effects
so why is additional gram neg cov still rec empirically?
to broaden spectrum of gram neg coverage in pt who are at risk for MDRO or death
prevent death
when to de-escalate?
- positive culture with documented susceptibility
OR neg blood and resp cultures
AND
clinically imrpoving
How to de-escalate?
positive blood and or resp culture
- maintain cov for org grown
neg blood or resp culture
- maintain cov for gram neg bacilli and MSSA (complete therapy for ab covering gram neg and mSSA)
how to monitor for efficacy of tx?
clniical improvement expected in 72h
- less cough, chest pain, SOB, fever, WBC, tachypnea, o2 req
- elderly or those with multiple comorb may take longer
what is the rec tx duration?
7 days, regardless of pathogen
** no burkholderia- coz pt in hospital, should not be exposed to contaminated soil or water
