Nosocomial Pneumonia

Question 1

How to prevent HAP/VAP?

Answer 1

• hand hygiene
• judicious use of abx and medications with sedative effects
• for VAP specifically, limit duration of mechanical ventilation; minimise duration and deep levels of sedation; elevate head of bed by 30 degrees

Question 2

Microbiology for HAP/VAP?

Answer 2

Compared to CAP, wider range of potential organisms and more MDRO (multi drug resistant organism).

Question 3

At minimum, what do we need to cover for HAP and VAP?

Answer 3

Empirically cover for staphylococcus aureus (MSSA) and Pseudomonas aeruginosa.

May need additional coverage:

• MDRO risk factors
• Mortality risk factors
• Antibiogram

Question 4

What are the MDRO risk factors for HAP?

Answer 4

Prior IV antibiotics within 90 days

Question 5

What are the MDRO risk factors for VAP?

Answer 5

Any ONE of the following:

• prior IV abx within 90 days
• septic shock at the time of VAP onset
• acute respiratory distress syndrome (ARDS) preceding VAP onset
• at least 5 days of hospitalisation prior to VAP onset
• acute renal replacement therapy prior to VAP

Question 6

What are the mortality risk factors for HAP?

Answer 6

For HAP ONLY: any ONE of the following:

• requiring mechanical ventilation as a result of HAP
• in septic shock

Question 7

What is the backbone regimen for ALL HAP patients?

Answer 7

Need to cover at least MSSA and pseudomonas.

Anti pseudomonal beta lactam (pip/tazo 4.5g IV Q6-8H* OR cefepime 2g IV Q8H* OR meropenam 1g IV Q8H* or imipenam 500mg IV Q6H*). Don’t use carbepenams as first line, need to conserve. Ceftazidime not here as does not have good gram pos coverage, cannot cover MSSA or strep pneumoniae.

OR
If severe penicillin allergy,
Use anti pseudomonal FQ (levofloxacin 750mg IV Q24H*)

Question 8

Indications for empiric MRSA coverage for HAP?

Answer 8

• MDRO risk factor OR
• mortality risk factor OR
• MRSA prevalence > 20% or unknown

If indicated, ADD to backbone regimen:

• vancomycin 15mg/kg IV Q8-12H* (more commonly used) OR
• Linezolid 600mg IV Q12H

Question 9

Indications for additional gram neg coverage for HAP?

Answer 9

• MDRO risk factor OR
• mortality risk factor

If indicated, ADD to backbone regimen:
AG: Gentamicin 5-7mg/kg IV Q24H* OR Amikacin 15mg/kg IV Q24H* OR Tobramycin OR
FQ: Ciprofloxacin 400mg IV Q8-12H* OR Levofloxacin 750mg IV Q24H*
(Add a drug that is of a different class as backbone regimen)

Question 10

Backbone regimen for VAP?

Answer 10

Need to cover at least MSSA and pseudomonas.

Anti pseudomonal beta lactam (pip/tazo 4.5g IV Q6-8H* OR cefepime 2g IV Q8H* OR meropenam 1g IV Q8H* or imipenam 500mg IV Q6H*). Don’t use carbepenams as first line, need to conserve. Ceftazidime not here as does not have good gram pos coverage, cannot cover MSSA or strep pneumoniae.

OR
If severe penicillin allergy,
Use anti pseudomonal FQ (levofloxacin 750mg IV Q24H*)

Question 11

Indications for empiric MRSA coverage for VAP patients?

Answer 11

• MDRO risk factor OR
• MRSA prevalence > 10% or unknown

If indicated, ADD to backbone regimen:

• vancomycin 15mg/kg IV Q8-12H* (more commonly used) OR
• Linezolid 600mg IV Q12H

Question 12

Indications for additional gram neg coverage for VAP patients?

Answer 12

• MDRO risk factor OR
• Single anti-pseudomonal agent in backbone regimen with activity < 90% or unknown

If indicated, ADD to backbone regimen:
AG: Gentamicin 5-7mg/kg IV Q24H* OR Amikacin 15mg/kg IV Q24H* OR Tobramycin OR
FQ: Ciprofloxacin 400mg IV Q8-12H* OR Levofloxacin 750mg IV Q24H*
(Add a drug that is of a different class as backbone regimen)

Question 13

When do we deescalate therapy for HAP/VAP?

Answer 13

• clinically improving AND
• positive cultures with documented susceptibility OR negative blood and respiratory cultures

For positive blood or respiratory cultures, maintain coverage for organisms grown (culture directed therapy).
For negative cultures, maintain coverage for pseudomonas and MSSA (backbone therapy, stop others)

Question 14

Treatment duration for HAP/VAP?

Answer 14

7 days