NOSOCOMIAL PNEUMONIA

Question 1

Types of nosocomial pneumonia

Answer 1

hospital acquired and ventilator acquired pneumonia

Question 2

patient related risk factors of nosocomial pneumonia

Answer 2

1. elderly
2. smoking
3. COPD, cancer, immuno
4. prolonged hospitalisation
5. coma, impaired consciousness
6. malnutrition

Question 3

infection control-related risk factors of nosocomial pneumonia

Answer 3

1. hand-hygiene compliance

2. contaminated respiratory care devices

Question 4

healthcare related risk factors of nosocomial pneumonia

Answer 4

1. prior antibiotic use
2. sedatives
3. opioid analgesics
4. mechanical ventilation
5. supine position

Question 5

prevention strategies of nosocomial pneumonia

Answer 5

1. practice consistent hand hygiene
2. judicious use of antibiotics and medications with sedative effects
3. limit duration of mechanical ventilation (VAP specific)
4. minimise duration and deep level of sedation (VAP specific)
5. elevate head of bed by 30 degree (VAP specific)

Question 6

microbiology of HAP/VAP

Answer 6

gram pos:

1. streptococcus pneumoniae
2. staphylococcus aureus

gram neg:

1. haemophilus influenzae
2. escherichia coli
3. proteus spp.
4. serratia marcescens
5. enterobacter spp
6. klebsiella pneumoniae (MDR strain)
7. acinetobacter spp (MDR strain)
8. psuedomonas aeruginosa (MDR strain)

Question 7

principle of empiric therapy for VAP/HAP

Answer 7

• minimally cover staphylococcous aureus MSSA and pseudomonas aeruginosa
• additional coverage for MRSA (MDRO risk factor/mortality risk/ MRSA prevalence)
• additional coverage for gram neg (MDRO risk/ mortality risk/ pseudomonal coverage <90%)

Question 8

MDRO risk factors for HAP

Answer 8

1. prior IV antibiotics within 90d

Question 9

MDRO risk factor for VAP

Answer 9

1. prior IV antibiotics within 90d
2. septic shock (hypotension requiring vasoactive meds) at time of VAP onset
3. acute respi distress syndrome ARDS (hypoxemic respi failure requiring venti.) preceding VAP onset
4. > =5d hopsitalisation prior to VAP
5. acute renal replacement therapy prior to VAP

Question 10

Mortality risk factor

Answer 10

only relevant to HAP

1. requiring mechanical venti from HAP
2. in septic shock (hypotensive + need vasoactive meds)

Question 11

empiric therapy for HAP / VAP

Answer 11

1. anti-pseudomonal beta lactam (pipe/tazo or cefepime or meropenem or imipenem
2. Anti pseudomonal FQ (levo)

Question 12

why is ceftazidime not used in HAP/VAP empiric

Answer 12

lack gram pos coverage

Question 13

why is ciprofloxacin not used in HAP/VAP empiric

Answer 13

lack gram pos coverage

Question 14

when to add MRSA coverage for HAP

Answer 14

when patient either:

1. has MDRO risk factors
2. have mortality risk factors
   3: MRSA prevalence >20% or is unknown

Question 15

when to add additional gram -ve coverage for HAP

Answer 15

when patient either:

1. has MDRO risk factor
2. has mortality risk

Question 16

when to add MRSA coverage for VAP

Answer 16

when patient either:

1. MDRO risk factor
2. MRSA prevalence >10-20% or unknown

Question 17

when to add additional gram -ve coverage for VAP

Answer 17

when patient either:

1. MDRO risk factor
2. single use anti-pseudomonal susceptibility <90% or unknown

Question 18

what to add for MRSA coverage for HAP/VAP

Answer 18

1. vanco IV 625mg

2. linezolid

Question 19

what to add for gram -ve coverage for HAP/VAP

Answer 19

1. aminoglycosides: genta, amika, tobra

2. fluoroquinolones: levo, cipro

Question 20

why is additional gram-ve recommended empirically

Answer 20

broaden gram neg coverage in patients who are at risk for MDRO or death, in case currently agent not provide sufficient coverage

Question 21

when to de-escalate tx

Answer 21

• clinical improvement
• positive cultures with documented suspectibility
• negative blood and respi culture

Question 22

how to de-escalate

Answer 22

1. positive blood and/or respi cultures:
   - maintain coverage of organisms grown
2. negative blood and/or respi culture:
   - maintain coverage of gram neg bacilli and MSSA

Question 23

efficacy of HAP/VAP tx

Answer 23

• clinical improvements expected in 72h

- reduce cough, chest pains, SOB, fever, WBC, tachypnea, O2 requirement

Question 24

monitoring HAP/VAP safety

Answer 24

• ADR: diarrhea, rash

- renal function

Question 25

duration of treatment of HAP/VAP

Answer 25

7d regardless of pathogen