Nosocomial Pneumonia

Question 1

Define Hospital-acquired pneumonia (HAP)

Answer 1

Onset ≥ 48 hrs after hospital admission

Question 2

Define Ventilator-associated pneumonia (VAP)

Answer 2

Onset ≥ 48 hrs after mechanical ventilation

Question 3

What are some patient-related risk factors of nosocomial pneumonia?

Answer 3

1) elderly ≥ 65 yo
2) smoking
3) comorbidities: COPD, cancer, immunosuppression, HIV
4) Prolonged hospitalization
5) coma/ impaired consciousness (risk for aspiration)
6) malnutrition (weaker immunity)

Question 4

What are some infection control related risk factors of nosocomial pneumonia?

Answer 4

1) poor hand hygiene

2) Contaminated respiratory care devices

Question 5

What are some healthcare-related risk factors of nosocomial pneumonia?

Answer 5

1) Prior antibiotic use
2) Sedatives
3) Opioid analgesics
4) mechanical ventilation
5) Supine position

Question 6

How can nosocomial pneumonia be prevented?

Answer 6

1) practice consistent hand hygiene
2) mindful use of sedating medications & antibiotics

3) for VAP:
- limit duration on ventilation
- reduce duration & level of deep sleep sedation (affects consciousness)
- elevate head of bed by 30°

Question 7

What are the causative organisms of nosocomial pneumonia?

Answer 7

Gram-Positive: Strep pneumo, S. Aureus

Gram-Negative:

1) H influenzae
2) E. Coli
3) Proteus
4) Serratia marcescens
5) Enterobacter
6) Klebsiella pneumo
7) Acinetobacter
8) P. aeruginosa

Question 8

Empiric antibiotics should always minimally cover __________________

Answer 8

MSSA & P. aeruginosa

Question 9

What is/are Multi-drug resistant Organism (MDRO risk factors for HAP?

Answer 9

IV antibiotic use in last 90 days

Question 10

What is/are Multi-drug resistant Organism (MDRO risk factors for VAP?

Answer 10

1) IV antibiotic use in last 90 days
2) Septic shock
3) Acute respiratory distress syndrome (ARDS)
4) ≥ 5 days of hospitalization prior to onset
5) Acute renal replacement therapy

Question 11

What are the 2 Mortality risk factors in HAP?

Answer 11

1) mechanical ventilation

2) septic shock

Question 12

Which organisms do the backbone regimen for HAP & VAP cover?

Answer 12

1) Strep pneumo
2) MSSA
3) P aeruginosa
4) antibiotic-sensitive Enterobacteriaceae: (KEEPS)
- Klebsiella
- E. coli
- Enterobacter
- proteus
- Serratia marcescens

Question 13

Describe the backbone empiric therapy regimen for HAP & VAP

Answer 13

1. Antipseudomonal β-lactam
   - pip/tazo
   - cefepime (X ceftazidime due to poor gram pos coverage)
   - meropenem/ imipenem
2. Antipseudomonal resp FQ (Levo)

Question 14

What are the indications for MRSA coverage in HAP?

Answer 14

ANY:
1) MDRO risk factor (IV antibiotics in last 90 d)

2) Mortality risk factor (Mech Vent/ septic shock)
3) MRSA prevalence of > 20% or unknown

Question 15

How is the treatment regimen modified for MRSA coverage in HAP/VAP?

Answer 15

add vanco (iv) / linezolid (po/iv)

Question 16

What are the indications for additional gram-negative coverage in HAP?

Answer 16

ANY:
1) MDRO risk factor (IV antibiotics in last 90 d)

2) Mortality risk factor (Mech Vent/ septic shock)

Question 17

How is the treatment regimen modified for additional gram-negative coverage in HAP/VAP?

Answer 17

Add to backbone regimen: (diff class fr backbone regimen)

• Aminoglycoside: Gentamicin/ amikacin/ tobramycin
• FQ: Cipro/ levo

Question 18

Why is Ciprofloxacin suitable for additional gram-negative coverage even though it is not considered a respiratory FQ?

Answer 18

It is not considered resp FQ due to poor gram +ve coverage & is unsuitable for the backbone regimen; however, it can still reach the lungs & exert effects on gram -ve organisms

Question 19

What are the indications for MRSA coverage in VAP?

Answer 19

ANY:
1) MDRO risk factor (IV antibiotics in last 90d/ septic shock/ ARDS/ ≥5d of hospitalization/ acute renal replacement)

2) MRSA prevalence of > 10% or unknown

Question 20

What are the indications for additional gram-negative coverage in VAP?

Answer 20

ANY:
1) MDRO risk factor (IV antibiotics in last 90d/ septic shock/ ARDS/ ≥5d of hospitalization/ acute renal replacement)

2) Any antipseudomonal agent w/ activity < 90% or unknown

Question 21

What is the rationale for recommending empiric additional gram-negative coverage despite poor evidence, higher costs & ADRs?

Answer 21

broaden gram-neg spectrum of activity esp in high-risk patients (in case 1 agent fails/ has inadequate coverage)

Question 22

What are the conditions for de-escalation of empiric therapy?

Answer 22

Clinically improving + Positive culture w/ susceptibility data/ negative culture

Question 23

How can therapy be de-escalated if the patient has positive cultures with documented susceptibility?

Answer 23

Maintain coverage for organisms grown based on susceptibility data

Question 24

How can therapy be de-escalated if the patient has negative cultures?

Answer 24

Maintain coverage for MSSA & P. aeruginosa

Question 25

How long does it typically take for clinical improvements to be observed?

Answer 25

~72 hrs

*elderly & those w/ comorbidities may take longer

Question 26

What is the recommended duration of therapy for HAP/VAP?

Answer 26

7 days regardless of the pathogen