Hospital Acquired Pneumonia (HAP)

Question 1

what are the most common causative organisms associated w HAP

Answer 1

pseudomonas aeruginosa
MSSA
MRSA
other gram negative rods: e. coli, klebsiella pneumoniae, enterobacter spp., acinetobacter spp., other enterobacterales

Question 2

What is recommended for empiric Abx therapy?

Answer 2

double anti-peusomonal coverage PLUS MRSA coverage

w agents from different classes, should include beta lactam

Question 3

Examples of beta lactams

Answer 3

cefepime
Zosyn
meropenem
aztreonam
imipenem
ceftazidime

Question 4

examples of fluoroquinolones

Answer 4

levofloxacin
ciprofloxacin

Question 5

examples of aminoglycosides

Answer 5

tobramycin

Question 6

examples of anti-MRSA agents

Answer 6

vancomycin
linezolid

Question 7

give 1 example of an empiric regimen

Answer 7

should include 1 beta lactam
cefepime + levaquin + vanco
meropenem + Cipro + vanco
zosyn + levaquin + linezolid
meropenem + tobramycin + linezolid

Question 8

Which cephalosporin is not used in empiric therapy and why?

Answer 8

ceftriaxone bc it does not cover pseudomonas

Question 9

what does the IDSA guidelines recommend for HAP in terms of gram negative coverage

Answer 9

should include pseudomonas aeruginosa
other gram negative considerations: double coverage
- IV Abx use past 90 days
- high risk for mortality

Question 10

what are MRSA risk factors

Answer 10

IV Abx use past 90 days
previous MRSA infection
hospitalization in a unit where > 20% SA isolates are MRSA

if unknown, cover for MRSA

Question 11

What dx test is used to indicated infection?

Answer 11

Nasal MRSA PCR

Question 12

what is recommended if covering for MSSA only?

Answer 12

choose agents that also cover pseudomas

zosyn, cefepime, levofloxacin, meropenem

Question 13

what do you monitor in HAP patients

Answer 13

renal function, vitals, therapeutic drug levels (vanco), repeat imaging, lab values (WBC, cultures)

Question 14

what is the duration for therapy according to the IDSA

Answer 14

7 days

use culture data to base duration on days of active therapy

Question 15

what is low phos associated with?

Answer 15

respiratory muscle weakness

improves after repletion

Question 16

if phos is 2.4-3.0 mg/dL, what is the repletion dose?

Answer 16

no replacement

Question 17

if phos is 1.6-2.3 mg/dL, what is the repletion dose?

Answer 17

0.16 mmol/kg

Question 18

if phos is 1.0-1.5 mg/dL, what is the repletion dose?

Answer 18

0.32 mmol/kg

Question 19

if phos is < 1.0 mg/dL, what is the repletion dose?

Answer 19

0.64 mmol/kg

Question 20

if a patient is hypotensive, what classes of meds should be dc?

Answer 20

ACEi/ARBs

Question 21

Propofol is known to cause what

Answer 21

hypotension

Question 22

what is an alternative to propofol?
to be used as a sedative agent for intubated patients

Answer 22

benzos, dexmedetomidine

Question 23

could consider keeping propofol in hypotensive patient for sedation if also using what?

Answer 23

vasopressors like norepinephrine

Question 24

renal adjustment for gabepentin

Answer 24

for CrCl ~ 51 ml/min
recommend max 1800 mg daily in 3 divided doses (600 mg q8h)

Question 25

renal adjustment for Beta lactams

Answer 25

Cefepime < 60 ml/min
meropenem < 50 ml/min
ceftazidime <50 ml/min
aztreonam < 30 ml/min
zosyn < 20 ml/min

Question 26

renal adjustment for FQ

Answer 26

levaquin < 50 ml/min
cipro < 30 ml/min

Question 27

renal adjustment for aminoglycoside

Answer 27

avoid aminoglycosides in renally impaired patients!!

Question 28

if carbapenem resistant pseudomas aeruginosa, what is a possible recommendation?

Answer 28

ceftolozane/tazobactam (zerbaxa)

reserve tobramycin