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PHRM 865 > Hospital/Ventilator Acquired Pneumonia (2-25-22) > Flashcards

Hospital/Ventilator Acquired Pneumonia (2-25-22) Flashcards

1
Q

What is hospital acquired pneumonia (HAP) defined as?

A

Pneumonia developing ≥ 48h after hospital admission

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2
Q

How is ventilator acquired pneumonia defined as?

A

Pneumonia developing > 48-72h after endotracheal intubation

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3
Q

How can one develop HAP or VAP?a

A
  1. ) Microaspiration (most common)
    - The oropharyngeal secretions colonized with bacteria get in to lung
    - Normally the oropharynx is colonized with gram positive. But after 3-5 days in hospital it changes to GRAM NEGATIVE
  2. ) Direct inoculation of lung via intubation
  3. ) mechanical ventilation –> the endotracheal tube bypasses host defenses and impairs lower respiratory tract infections (cough, mucociliary clearnace)
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4
Q

What are the risk factors for developing HAP or VAP?

A
  1. ) Older age
  2. ) Duration in hospital
  3. ) Mechanical ventilator
  4. ) Endotracheal intubation
  5. ) Severity of underlying disease
  6. ) Presence of nasogastric tubes
  7. ) altered mental status
  8. ) previous antimicrobial therapy
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5
Q

What is the most common bacteria antigen seen for HAP and VAP?

A
  1. ) Aerobic gram-negative bacilli (70%)
    - Pseudomonas aeruginosa (10-20%)
    - Enteric Gram- negative bacilli (20-40%)
    - Acinetobacter (5-10%)

2.) Staph aureus (esp MRSA) - 20-30%

[Enteric Gram-negative bacilli =
1.) Escherichia coli
2.) Klebsiella
3.) Proteus
4.) Enterobacter
5.) Serratia
6.) Citrobacter
7.) Providencia]
PECKS PE
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6
Q

What are the risk factors for developing ANTIBIOTIC RESISTANCE for VAP?

A
  1. ) Previous IV antibiotic use in the past 90 days
  2. ) ≥ 5 days hospitalized before getting VAP
  3. ) Septic shock
  4. ) acute respiratory distress syndrome BEFORE VAP
  5. ) acute renal replacement therapy prior to VAP
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7
Q

What pts are at lower risk for developing antibiotic resistant VAP?

A

Patients in coma at time of ICU admission

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8
Q

After how many days of hospitalization are pts more likely to develop MDR for VAP?

A

5 days or more

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9
Q

What are the risk factors for multidrug resistance in patients with HAP?

A

Previous antibiotic IV use within the past 90 days

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10
Q

What are the risk factors for developing antibiotic resistance from MRSA HAP/VAP?

A
  1. ) Prior antibiotic IV use within past 90 days

2. ) More likely in late onset HAP/VAP

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11
Q

What are the risk factors for developing antibiotic resistance from pseudomonas aeruginosa HAP/VAP?

A

Prior IV antibiotic use within the past 90 days

IV antibiotics EX:
carbapenems, broad-spectrum cephalosporins, FQ

These are the ones that have activity against pseudomonas

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12
Q

Do you always have to treat an infection if do a respiratory culture for a patient and you have growth? Why or why not?

A

No! B/c growth doesn’t mean pathogens. We have a diagnostic threshold

If <10^4 CFU/mL organisms present = don’t have to treat

IF > 10^4 CFU/mL = meets threshold so can treat

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13
Q

How to read an antibiogram?

A

The number inside the boxes mean the % of the specific bacteria that is susceptible or inhibited by the antibiotic

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14
Q

For empiric treatment of suspected VAP, what pathogens should it all cover?

A
  1. ) Pseudomonas aeruginosa
  2. ) Other gram-negative bacilli (PECK PE)
  3. ) Staph. aureus (including MRSA –> vanc or linezolid)
  4. ) Include active agent against MRSA IF:
    - risk factors for MRSA
    - pts treated in ICUs where >10-20% of S. aureus isolates are methicillin resistant
    - pts treated in ICUs and don’t know MRSA prevalence
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15
Q

What are the options for determining which regimen to use for suspected VAP empiric therapy?

A
  1. ) Give 2 antipseudomonal antibiotics from DIFF classes ONLY in pts who have:
    - risk factors for antimicrobial resistance
    - in ICUs where >10% of gram negative isolates are resistant to monotherapy agent
    - in ICUs where local resistance rates unknown
  2. ) Give empiric MONOtherapy for pseudomonas aeruginosa in:
    - pts w/o risk factors for antimicrobial resistance
    - pts in ICU where < 10% of gram negative isolates are resistant to monotherapy agent
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16
Q

What are drugs used to treat suspected VAP?

A

Gram positive antibiotics with MRSA activity:
1. )Vancomycin
OR
2.) Linezolid

B-lactam antibiotics with antipseudomonal activity:
1.) Zosyn 
OR
2.) Cefepime 
2.) Ceftazidime 
OR
3.) Imipenem 
3.) Meropenem 
OR
Aztreonam 
Non-b-lactam antibiotic w/ antipseudomonal activity:
1.) Cipro or levo
OR
2.) Amikacin or Gent or tobramycin (AMG)
OR
3.) Colistin or polymyxin B
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17
Q

What is the recommended EMPIRIC regimen for HAP if NOT at high risk of mortality and no factors increasing likelihood of MRSA? (can cover MSSA)

A
  1. ) pipercillin/tazobactam
  2. ) cefepime
  3. ) imipenem
  4. ) meropenem
  5. ) levofloxacin
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18
Q

What is considered as high risk for mortality?

A
  1. ) Need for ventilatory support

2. ) septic shock

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19
Q

What is the recommended empiric drug regimen if pt is not at high risk of mortality but has factors increasing likelihood of MRSA?

A
  1. ) Give ONE of following:
    - Zosyn
    - Cefepime
    - ceftazidime
    - imipenem
    - meropenem
    - levofloxacin
    - ciprofloxacin
    - aztreonam

PLUS
2.) vancomycin or linzolid

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20
Q

What is the recommended empiric drug therapy for pts who are high risk of mortality or had IV antibiotics during the prior 90 days (risk factor for MRSA) for suspected HAP?

A
  1. ) Give TWO of the following:
    - zosyn
    - cefepime
    - ceftazidime
    - imipenem
    - meropenem
    - levofloxacin
    - ciprofloxacin
    - AMG
    - aztreonam

PLUS

2.) vancomycin or linezolid

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21
Q

What drugs do you not wanna give as monotherapy or as empiric use? Why?

A

1.) AMG b/c has poor lung penetration, nephrotoxicity, ototoxicity, lower clinical response rates in studeis

  1. ) polymyxins
    - b/c has nephrotoxicity and peripheral neuropathy
  2. ) Tigcycline
    - b/c poor outcomes, increased mortality
22
Q

Now if know the specific organism (pathogen specific), what are treatments for HAP and VAP?

A

Is based on susceptibility testing results

  1. ) MSSA - cefazolin, nafcillin, oxacillin
  2. ) MRSA - vancomycin, linezolid
  3. ) Enterobacterales - numerous options
  4. ) ESBL-producer –> carbapenem, ceftazidime/avibactam
  5. ) MBL-producer –> aztreonam + ceftazidime/avibactam empirically; aztreonam monotherapy if susceptible
  6. ) KPC producer –> ceftazidime/avibactam, meropenem/vaborbactam, imipenem/cilastatin/relebactam
  7. ) P. aeruginosa –> Ceftolozane/tazobactam, ceftazidime/avibactam
  8. ) Acinetobacter species –> carbapenem or ampicillin/sulbactam (give cefiderocol if resistant to carbapenem or amp/sulbactam)
23
Q

What are drug options if know you have MSSA HAP or VAP?

A

Cefazolin
nafcillin
oxacillin

24
Q

What are drug options if know you have MRSA HAP or VAP?

A

vancomycin

linezolid

25
Q

What are drug options if know you have ESBL-producer HAP or VAP?

A

carbapenem

ceftazidime/avibactam

26
Q

What are drug options if know you have KPC-producer HAP or VAP?

A

ceftazidime/avibactam
meropenem/vaborbactam
imipenem/cilastatin/relebactam

27
Q

How long should therapy for HAP or VAP be?

A

7 days

28
Q

What is important lab value to look at for antibiotic therapy? Why?

A

Procalcitonin. Can help guide d/c of antibiotic therapy in HAP/VAP

29
Q

What causes (etiology) acute bronchitis?

A

Respiratory viruses

30
Q

What does acute bronchitis look like?

A

Cough
Coryza (inflammation of lining of nose)
Normal chest x ray

31
Q

How to tell difference between acute bronchitis (viral) and bacterial CAP?

A

A Chest x ray

Acute bronchitis, theirs looks normal

32
Q

Acute bronchitis treatment?

A

Should just go away with time. DON’T give antibiotics b/c viral etiology

Symptomatic treatment:

  1. ) antitussives (cough supressant)
  2. ) antipyretics
  3. ) adequate hydration

AVOID corticosteroids

33
Q

Can you give antibiotics in everyone with acute bronchitis?

A

No, not helpful at all b/c etiology is VIRAL

34
Q

What can cause acute exacerbations of chronic bronchitis?

A
  1. ) chronic inhalation of irritants that decrease normal secretory function (cigarette smoke, occupational dust, fumes)
  2. ) bronchial wall thickens –> increase in mucus secreting goblet cells –> hypertrophy of mucus glands
  3. ) increased mucous product –> further impairment of normal lung defenses
35
Q

What is acute exacerbation of chronic bronchitis?

A

A chronic cough productive of sputum on most days for at least 3 consecutive months

36
Q

What are the 3 cardinal symptoms of acute exacerbation of chronic bronchitis?

A
  1. ) increased cough or SOB
  2. ) increased sputum volume
  3. ) increased sputum purulence
37
Q

What dose having the 3 cardinal symptoms of ABCB mean?

A

If only has 1 cardinal symptom: no need to treat w/ antibiotics

If have 2 or 3 cardinal symptoms = pt will benefit from therapy

38
Q

What bacteria is commonly seen in AECB?

A
  1. ) H. influenzae (45%)
  2. ) S. pneomoniae (20%)
  3. ) M. catarrhalis (30%)
  4. ) Enterobacterales. P. aeruginosa (5%) –> seen in pts with end stage COPD (FEV1 < 40%)
39
Q

Treatment period for AECB?

A

5-7 days

40
Q

What antibiotics have a longer “infection free period” for treatment of acute exacerbation of chronic bronchitis (AECB)? Is this good or bad? Why?

A

FQ, amoxicillin/clavulanate, azithromycin

Good b/c the more exacerbations you have = worsening lung function –> thus want to have drug with longest possible infection free period

41
Q

What are the risk factors for resistance for AECB?

A 
age
>4 exacerbations/year
cardiac disease 
antibiotic use in previous 3 months
recent corticosteroid use
42
Q

What is the criteria for uncomplicated AECB? Treatment options?

A
  1. ) Age < 65
  2. ) FEV1 > 50%
  3. ) < 4 exacerbations/year
  4. ) No comorbid conditions
  5. ) no risk factors

Treatment options:

  1. ) 2nd gen macrolide
  2. ) 2nd or 3rd gen cephalo
  3. ) doxycycline
  4. ) amoxicillin
  5. ) TMP/SMX
43
Q

What is the criteria for complicated AECB? Treatment options?

A
  1. ) age > 65
  2. ) FEV <50%
  3. ) ≥ 4 exacerbations/year
  4. ) ≥ 2 risk factors

1st choice: amoxicillin/clavulanate
- respiratory FQ

44
Q

What is the criteria for complicated with risk for infection w/ P. aeruginosa for AECB?

A
  1. ) severe symptoms
  2. ) constant purulent sputum
  3. ) FEV1 < 35% predicted
  4. ) ≥ 2 risk factors (esp. prior antibiotics or steroids)

FQ w/ antipseudomonal activity (levo, moxi, gemi),
pip/tazo

45
Q

What are the most common causes of pharyngitis?

A
  1. ) viruses (rhinovirus, coronavirus, adenovirus) –> most common
  2. ) Strep. pyogenes –> most common bacterial pathogen
46
Q

Why is it important to treat pharyngitis early?

A

B/d untreated pts are infectious during and for 1 week after acute illness

and effective treatment becomes ineffective to 24 hours

47
Q

Symptoms of pharyngitis?

A

Sudden onset of sore throat w/ dysphagia, fever

- Red swollen uvula

48
Q

Pharyngitis treatment?

A
  1. ) symptomatic care for all pts
    - antipyretics
  2. ) group A streptococci (bacterial)
    - Penicillin V (DRUG OF CHOICE)
    - Amoxicillin (2nd DOC)
    - 2nd gen oral cephalosporins
49
Q

What is the treatment for pharyngitis if penicillin allergic?

A
  1. ) 1st gen cephalosporin x 10 days (not anaphylaxis)
  2. ) macrolide (concern for resistance)
  3. ) clindamycin
50
Q

sdf

A

PHRM 865 (6 decks)

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