Nosocomial Pneumonia

Question 1

Why should antibiotics be started ASAP?

Answer 1

Associated with significant healthcare cost -> prolonged hospitalization
Mortality rate of 20-30%

Question 2

Patient-related risk factors

Answer 2

• Elderly
• Smoking
• COPD, cancer, immunosuppression
• Prolonged hospitalization
• Coma, impaired consciousness: difficulty controlling swallowing -> increased risk for aspiration
• Malnutrition

Question 3

What are some healthcare-related risk factors?

Answer 3

• Prior abx use: alter normal flora -> increase risk for infx and resistance
• Mechanical ventilation: connect to external environment
  Increased risk for aspiration
• Sedatives or opioid analgesics
• Supine position

Question 4

How can we prevent HAP/VAP?

Answer 4

• Consistent hand hygiene
• Judicious use of antibiotics & medications with sedative properties
  VAP:
• Limit duration of mechanical ventilation
• Minimise duration and deep levels of sedation
• Elevate head of bed by 30 degrees

Question 5

What are the organisms to empirically cover for HAP/VAP at minimum?

Answer 5

Staphylococcus aureus and Pseudomonas aeruginosa

Question 6

What are the MDRO risk factors for HAP and VAP?

Answer 6

HAP: prior antibiotic use in past 90 days
VAP: same as HAP
- Prior to onset: ARDS, acute renal replacement therapy, >5 days hospitalization
- Septic shock at onset

Question 7

What are the mortality risk factors?

Answer 7

HAP only

• requiring mechanical ventilation
• septic shock

Question 8

Empiric treatment for HAP/VAP

Answer 8

Anti‐pseudomonal 𝛃‐lactam 
- IV piperacillin/tazobactam 4.5g q6-8h
- IV cefepime 2g q6-8h
- IV meropenem 1g q8h OR imipenem 500mg q6h
OR
Anti‐pseudomonal fluoroquinolone
- IV levofloxacin 750mg q24h

Question 9

Why are ceftazidime and ciprofloxacin not used?

Answer 9

Poor gram positive coverage

Question 10

Empiric MRSA coverage in HAP

Answer 10

Indicated with any 1:

• 1 MDRO risk factor
• 1 Mortality risk factor
• MRSA prevalence >20% or unknown

Question 11

What antibiotics can be used for additional MRSA coverage?

Answer 11

IV Vancomycin 15mg/kg q8-12h

IV Linezolid 600mg q12h

Question 12

Empiric MRSA coverage in VAP

Answer 12

Indicated with any 1:

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

Question 13

When is additional Gram-negative coverage indicated?

Answer 13

Any 1 of the following:
MDRO risk factor
HAP: mortality risk factor
VAP: single anti-pseudomonal agent in backbone with activity <90% or unknown

Question 14

Which antibiotics can be used for additional Gram-negative coverage?

Answer 14

IV Gentamicin 5-7mg/kg q24h
IV Amikacin 15mg/kg q24h
IV Tobramycin (not available in SG)
IV Ciprofloxacin 500mg q8-12h
IV Levofloxacin 750mg q24h

Question 15

What is the rationale for additional Gram-negative coverage?

Answer 15

Empirically broaden spectrum of gram-negative coverage in patients who are at risk for MDRO or death (in case 1 agent does not provide sufficient coverage)
*even though clinical data does not show difference in mortality, length of stay, treatment failure rates

Question 16

When should we de-escalate?

Answer 16

1. Clinical improvement +

2. Either positive culture w/ documented susceptibility OR negative blood & respiratory culture

Question 17

How to de-escalate based on blood and/or respiratory cultures?

Answer 17

Positive cultures: maintain coverage for organisms grown

Negative cultures: maintain backbone therapy -> coverage for Gram-negative bacilli & MSSA

Question 18

Monitoring for safety of therapy

Answer 18

Adverse effects (e.g. diarrhoea, rash)
Renal function

Question 19

Monitoring for efficacy of therapy

Answer 19

Similar to CAP: Clinical improvements expected in 72 h

• Cough, chest pain, SOB, fever, WBC, tachypnea, oxygen requirement, etc.
• Elderly patients and those with multiple co‐morbidities may take longer

Question 20

Treatment duration

Answer 20

7 days regardless of pathogen

- no difference in recurrence and mortality

Question 21

What are some other organisms that can cause HAP/VAP?

Answer 21

Gram-positive: Streptococcus pneumoniae
Gram-negative: Haemophilus influenzae, E. coli, Proteus spp, Serratia marcescens, Enterobacter spp
MDR Gram-negative: Klebsiella pneumoniae, Acinetobacter spp, Pseudomonas aeruginosa