Nosocomial Pneumonia Flashcards
Define Hospital-acquired pneumonia (HAP)
Onset ≥ 48 hrs after hospital admission
Define Ventilator-associated pneumonia (VAP)
Onset ≥ 48 hrs after mechanical ventilation
What are some patient-related risk factors of nosocomial pneumonia?
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)
What are some infection control related risk factors of nosocomial pneumonia?
1) poor hand hygiene
2) Contaminated respiratory care devices
What are some healthcare-related risk factors of nosocomial pneumonia?
1) Prior antibiotic use
2) Sedatives
3) Opioid analgesics
4) mechanical ventilation
5) Supine position
How can nosocomial pneumonia be prevented?
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°
What are the causative organisms of nosocomial pneumonia?
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
Empiric antibiotics should always minimally cover __________________
MSSA & P. aeruginosa
What is/are Multi-drug resistant Organism (MDRO risk factors for HAP?
IV antibiotic use in last 90 days
What is/are Multi-drug resistant Organism (MDRO risk factors for VAP?
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
What are the 2 Mortality risk factors in HAP?
1) mechanical ventilation
2) septic shock
Which organisms do the backbone regimen for HAP & VAP cover?
1) Strep pneumo
2) MSSA
3) P aeruginosa
4) antibiotic-sensitive Enterobacteriaceae: (KEEPS)
- Klebsiella
- E. coli
- Enterobacter
- proteus
- Serratia marcescens
Describe the backbone empiric therapy regimen for HAP & VAP
- Antipseudomonal β-lactam
- pip/tazo
- cefepime (X ceftazidime due to poor gram pos coverage)
- meropenem/ imipenem - Antipseudomonal resp FQ (Levo)
What are the indications for MRSA coverage in HAP?
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
How is the treatment regimen modified for MRSA coverage in HAP/VAP?
add vanco (iv) / linezolid (po/iv)
What are the indications for additional gram-negative coverage in HAP?
ANY:
1) MDRO risk factor (IV antibiotics in last 90 d)
2) Mortality risk factor (Mech Vent/ septic shock)
How is the treatment regimen modified for additional gram-negative coverage in HAP/VAP?
Add to backbone regimen: (diff class fr backbone regimen)
- Aminoglycoside: Gentamicin/ amikacin/ tobramycin
- FQ: Cipro/ levo
Why is Ciprofloxacin suitable for additional gram-negative coverage even though it is not considered a respiratory FQ?
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
What are the indications for MRSA coverage in VAP?
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
What are the indications for additional gram-negative coverage in VAP?
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
What is the rationale for recommending empiric additional gram-negative coverage despite poor evidence, higher costs & ADRs?
broaden gram-neg spectrum of activity esp in high-risk patients (in case 1 agent fails/ has inadequate coverage)
What are the conditions for de-escalation of empiric therapy?
Clinically improving + Positive culture w/ susceptibility data/ negative culture
How can therapy be de-escalated if the patient has positive cultures with documented susceptibility?
Maintain coverage for organisms grown based on susceptibility data
How can therapy be de-escalated if the patient has negative cultures?
Maintain coverage for MSSA & P. aeruginosa
How long does it typically take for clinical improvements to be observed?
~72 hrs
*elderly & those w/ comorbidities may take longer
What is the recommended duration of therapy for HAP/VAP?
7 days regardless of the pathogen
