HAP/VAP Nosocomial Pneumonia

Question 1

Definition of Hospital Acquired Pneumonia (HAP)

Answer 1

> = 48h after hospitalisation

Question 2

Definition of Ventilation Associated Pneumonia (VAP)

Answer 2

> = 48h after mechanical ventilation

Question 3

HAP & VAP risk factors (infection control related)

Answer 3

1. Hand hygiene compliance

2. Contaminated respiratory care devices

Question 4

HAP & VAP prevention strategies

Answer 4

1. Practice consistent hand hygiene
2. Judicious use of antibiotics and medication with sedative effects

Mainly VAP

1. Limit duration of ventilation
2. Minimise duration and deep levels of sedation
3. Elevate head of bed by 30 degrees

Question 5

HAP & VAP prevention strategies

Answer 5

1. Practice consistent hand hygiene
2. Judicious use of antibiotics and medication with sedative effects

Mainly VAP

1. Limit duration of ventilation
2. Minimise duration and deep levels of sedation
3. Elevate head of bed by 30 degrees

Question 6

HAP and VAP empiric coverage (backbone)

Answer 6

1. Anti-pseudomonal Beta-Lactams
   - IV Piperacillin/Tazobactam 4.5g q6-8h
   - IV Cefepime 2g q8h
   - IV Meropenem 1g q8h
   - IV Imipenem 500mg q6h
2. Anti-pseudomonal fluoroquinolone
   IV Levofloxacin 750mg q24h

To cover for Pseudomonas and Staph aureus (MSSA)

Question 7

HAP and VAP empiric coverage (backbone)

Answer 7

1. Anti-pseudomonal Beta-Lactams
   - IV Piperacillin/Tazobactam 4.5g q6-8h
   - IV Cefepime 2g q8h
   - IV Meropenem 1g q8h
   - IV Imipenem 500mg q6h
2. Anti-pseudomonal fluoroquinolone
   IV Levofloxacin 750mg q24h

To cover for Pseudomonas and Staph aureus (MSSA)

Question 8

HAP Mortality risk factors (2)

Answer 8

1. Septic shock requiring vasoactive medications

2. Requiring mechanical ventilation as a result of HAP

Question 9

VAP MDRO risk factors (5)

Answer 9

1. IV antibiotics within 90 days
2. Acute Respiratory Distress (ARD) at onset
3. Acute Renal Transplant therapy prior to VAP
4. Hospitalisation >= 5 days prior to VAP
5. Septic shock at onset

Question 10

VAP MDRO risk factors (5)

Answer 10

1. IV antibiotics within 90 days
2. Acute Respiratory Distress (ARD) at onset
3. Acute Renal Transplant therapy prior to VAP
4. Hospitalisation >= 5 days prior to VAP
5. Septic shock at onset

Question 11

When to consider MRSA coverage for HAP

Answer 11

1. MDRO
2. Mortality risk
3. MRSA prevalence (>20% or unknown)

(any one)

Question 12

MRSA coverage treatment (both HAP & VAP)

Answer 12

1. IV Vancomycin 15mg/kg q8-12h

2. IV Linezolid 600mg q12h

Question 13

When to consider additional gram-ve coverage for HAP

Answer 13

1. MDRO
2. Mortality risk

(any one)

Question 14

Additional gram-ve coverage (both HAP & VAP)

Answer 14

1. IV Gentamicin 5-7mg/kg q24h
2. IV Amikacin 15mg/kg q24h
3. Tobramycin
4. IV Ciprofloxacin 400mg q8-12h
5. IV Levofloxacin 750mg q24h

(different class as backbone)

Question 15

When to consider MRSA coverage for HAP

Answer 15

1. MDRO

2. MRSA prevalence (10-20% or unknown)

Question 16

When to consider additional gram-ve coverage for HAP

Answer 16

1. MDRO

2. Single antipseudomonal activity <90% or unknown

Question 17

Reason for double negative coverage

Answer 17

Broadens spectrum of activity for ppl at risk of MDRO and death
BUT clinical data shows no difference in mortality, hospital stays and treatment failure rates

Question 18

How to de-escalate treatment

Answer 18

According to AST and cultures. Otherwise, keep backbone for gram-ve bacilli (pseudomonas) & MSSA (piperacillin/tazo, cefepime, meropenem, imipenem, levofloxacin)

Question 19

Duration of antibiotics treatment

Answer 19

7 days regardless of pathogens

Question 20

HAP & VAP risk factors (patient-related)

Answer 20

1. Elderly
2. Smoking
3. COPD, cancer, immunosuppression
4. Prolonged hospitalisation
5. Coma, impaired consciousness
6. Malnutrition

Question 21

HAP & VAP risk factors (healthcare related)

Answer 21

1. Prior antibiotics used
2. Sedatives
3. Opioids analgesics
4. Mechanical ventilation
5. Supine position