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Nosocomial Pneumonia Flashcards

1
Q

What is the definition of HAP (vocabulary)?

A

Onset 48 or more hours after hospital admission

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2
Q

What is the definition of VAP (vocabulary)?

A

Onset 48 or more hours after mechanical ventilation

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3
Q

What is the definition of CAP (vocabulary)?

A

Onset in the community or < 48 hours after hospital admission

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4
Q

What is the urgency of starting abx for HAP/VAP?

A

IV abx to be initiated ASAP with clinical suspicion

*HAP/VAP is a severe disease with 20-30% mortality

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5
Q

What are the patient related risk factors for HAP/VAP?

A 
Elderly
Smoking
COPD, cancer, immunosuppression
Prolonged hospitalization
Coma, impaired consciousness
Malnutrition
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6
Q

What are the infection control-related risk factors for HAP/VAP?

A

Hand hygiene compliance

Contaminated respiratory care devices

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7
Q

What are the Healthcare‐related factors for HAP/VAP?

A 
Prior antibiotic use
Sedatives
Opioid analgesics
Mechanical ventilation
Supine position
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8
Q

What are some strategies to prevent HAP/VAP?

A
  1. Practice consistent hand hygiene
  2. Judicious use of antibiotics and medications with sedative effects
  3. VAP specific
    – Limit duration of mechanical ventilation
    – Minimize duration and deep levels of sedation
    – Elevate head of bed by 30 degrees
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9
Q

What is the general microbiology of HAP/VAP compared to CAP?

A

Wider range of potential organisms and higher chance of multi‐drug resistant organisms (MDROs)
Streptococcus pneumoniae
Staphylococcus aureus*
Haemophilus influenzae
Escherichia coli
Proteus spp.
Serratia marcescens
Enterobacter spp.
Klebsiella pneumoniae (including MDR strains)
Acinetobacter spp. (including MDR strains)
Pseudomonas aeruginosa* (including MDR strains)

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10
Q

What is the minimum empiric cover for HAP/VAP like?

A

MSSA and Pseudomonas aeruginosa

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11
Q

What is the additional cover (MRSA/gram negatives) based on for HAP/VAP?

A
  • MDRO Risk Factors
  • Mortality risk factors
  • Local susceptibility (antibiogram)
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12
Q

What are the MDRO risk factors for HAP/VAP?

A

HAP/VAP: Prior IV antibiotics within 90 days
VAP:
- Septic shock at the time of VAP onset
- Acute respiratory distress syndrome (ARDS)† preceding VAP onset
- ≥ 5 days of hospitalization prior to VAP onset
- Acute renal replacement therapy prior to VAP

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13
Q

How is the kidney implicated in MDROs in pneumonia?

A
  • Renal failure is an indication of systemic s/sx of overwhelming infection (multi-organ dysfunction)
  • Common complication of septic shock

Note: must be acute (originally not on dialysis but needed to be on dialysis because of this VAP)
- Chronic/Baseline renal replacement (dialysis) does not count

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14
Q

What are the mortality risk factors for HAP/VAP?

A

– Requiring mechanical ventilation as a result of HAP

– In septic shock

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15
Q

How can we tell read the antibiogram to help us find out susceptibility of MRSA?

A

Find %SA NOT susceptible to Cloxacillin/Cephazolin

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16
Q

How can we tell read the antibiogram to help us find out susceptibility of ESBLs?

A

Find %Gram negs NOT susceptible to 3rd/4th gen cephalosporins

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17
Q

Can we use clindamycin susceptibility to find the local prevalence of MRSA?

A

No. Even MSSA can be resistant to clindamycin as well

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18
Q

Is there a need to cover for Burkholderia in HAP/CAP?

A

No. Exposure is from contaminated soil/water (hospital water supply safe

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19
Q

What is the ‘backbone’ regimen for HAP?

  • NO MDRO risk factors and NO mortality risk factors and NO indication for MRSA coverage
    (i. e. minimum coverage need for ALL HAP patients = MSSA and P. aeruginosa)
A

Anti‐pseudomonal Beta‐lactam (piperacillin/tazobactam OR cefepime OR meropenem OR imipenem)

OR (penicillin allergy)
Anti‐pseudomonal FQ (levofloxacin)

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20
Q

What are the organisms covered under the ‘backbone’ regimen for HAP?

A
  • Streptococcus pneumoniae
  • S. aureus (MSSA only)
  • Pseudomonas aeruginosa
  • Antibiotic‐sensitive Enterobacteriaceae (e.g. E. coli,
    K. pneumoniae, Enterobacter spp., Proteus spp., Serratia marcescens)
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21
Q

Why is ceftazidime not used for the ‘backbone’ regimen for HAP?

A

Poor gram positive cover (MSSA and strep pneumo)

22
Q

Why is ciprofloxacin not used for the ‘backbone’ regimen for HAP/VAP?

A

Does not cover Strep pneumoniae despite good lung penetration

23
Q

Why is moxifloxacin not used for the ‘backbone’ regimen for HAP/VAP?

A

Does not cover pseudomonas

24
Q

Which HAP patients require empiric MRSA cover?

A

MDRO risk factor; or
Mortality risk factor; or
MRSA prevalence > 20% or unknown

MDRO risk factor: prior IV antibiotics within 90 days
Mortality risk factors: mechanical ventilation, or septic shock

25
How can we add empiric MRSA cover for HAP?
IV Vancomycin | IV Linezolid
26
Which HAP patients require additional gram negative cover?
MDRO risk factor; or Mortality risk factor MDRO risk factor: prior IV antibiotics within 90 days Mortality risk factors: mechanical ventilation, or septic shock
27
How can we add additional empiric gram negative cover for HAP?
AGs: Gentamicin or Amikacin or Tobramycin OR FQs: Ciprofloxacin or Levofloxacin *Ensure 2 different drug classes are chosen
28
Why is ciprofloxacin used in providing additional gram negative cover in HAP?
Cipro provides excellent gram neg cover with lung penetration - antipseudomonal agent from backbone can cover the gram pos that cipro cannot cover
29
Which VAP patients require empiric MRSA cover?
MDRO risk factor; or MRSA prevalence > 10‐20% or unknown MDRO risk factor: prior IV antibiotics within 90 days, or septic shock, or ARDS, or hospitalization > 5 days, or acute renal replacement therapy
30
How can we add on empiric MRSA cover for VAP?
IV Vancomycin or IV Linezolid
31
Which VAP patients require additional empiric gram negative cover?
MDRO risk factor; or <90% susceptibility to anti-pseudomonal agent MDRO risk factor: prior IV antibiotics within 90 days, or septic shock, or ARDS, or hospitalization > 5 days, or acute renal replacement therapy
32
How can we add additional empiric gram negative cover in VAP?
AGs: Gentamicin or Amikacin or Tobramycin OR FQs: Ciprofloxacin or Levofloxacin *Ensure 2 different drug classes are chosen
33
What is the rationale for adding additional gram negative cover in HAP/VAP?
To broaden spectrum of gram‐negative coverage in patients who are at risk for MDRO or death (in case 1 agent does not provide adequate coverage) (to prevent death)
34
Clinically, is there any difference between linezolid and vancomycin for MRSA cover in pneumonia?
Equal level of recommendation (similar clinical outcomes) Vancomycin: + Cheaper, longer hx of use, experience in use (-) Therapeutic drug monitoring for renal function Linezolid: (+) better lung penetration and stable PK (-) $$$, bone marrow suppression, serotonin syndrome (blood count needed)
35
When should we de-escalate therapy in a HAP/VAP patient?
– Positive cultures with documented susceptibility; OR – Negative blood and respiratory cultures; AND clinically improving *Negative cultures alone w/o clinical improvement cannot allow de-escalation
36
How should we de-escalate therapy in a HAP/VAP patient when we have Positive blood and/or respiratory cultures?
Streamline to culture directed therapy
37
How should we de-escalate therapy in a HAP/VAP patient when we have Negative blood and/or respiratory cultures?
De-escalate to backbone regimen (pseudomonas and MSSA cover) | - Remove MRSA/additional gram neg cover, if any
38
What are the things to monitor for safety of tx?
– Adverse effects of antibiotics (e.g. diarrhea, rash) | – Renal function
39
What are the clinical improvements we can expect from appropriate abx tx?
– Clinical improvements expected in ~72 hours • ↓ Cough, chest pain, shortness of breath, fever, WBC, tachypnea, oxygen requirement, etc. • Elderly patients and/or those with multiple co‐morbidities may take longer
40
What is the treatment duration of HAP/VAP?
7 days regardless of pathogen
41
State the ROA, dose and frequency of Pip-tazo
4.5g IV q6-8h
42
State the ROA, dose and frequency of Cefepime
2g IV q8h
43
State the ROA, dose and frequency of Meropenem
1g IV q8h
44
State the ROA, dose and frequency of Imipenem
500g IV q6h
45
State the ROA, dose and frequency of Ciprofloxacin
400mg IV q8-12h
46
State the ROA, dose and frequency of Levofloxacin
750mg IV q24h
47
State the ROA, dose and frequency of Gentamicin
5-7mg/kg IV q24h
48
State the ROA, dose and frequency of Amikacin
15mg/kg IV q24h
49
State the ROA, dose and frequency of Vancomycin
15mg/kg IV q8-12h
50
State the ROA, dose and frequency of Linezolid
600mg IV q12h
51
58yo M intubated and admitted to ICU for close monitoring after heart surgery; 6 days later developed fever and worsening oxygenation on mechanical ventilation T 38.4C, BP 106/66, HR 96 WBC 17.8, Scr 86 Allergy: NKDA MRSA prevalence: 9%; P. aeruginosa: 89% S to pip/tazo Empiric abx?
Pt has VAP 1. MDRO risk factor: 5days or more hospitalization -> add vanco for MRSA cover - despite MRSA prevalence < 10% (either/or with MDRO risk factor enough) 2. Additional gram neg cover: <90% activity for pseudomonal cover + MDRO risk factor -> additional gram neg cover to backbone: AG/FQ 3. backbone tx: pip-tazo
52
58yo M intubated and admitted to ICU for close monitoring after heart surgery; 3 days later developed fever and worsening oxygenation on mechanical ventilation T 38.40C, BP 106/66, HR 96 WBC 17.8, Scr 86 Allergy: NKDA MRSA prevalence: 9%; P. aeruginosa: 89% S to pip/tazo
Pt has VAP 1. Additional gram neg cover: <90% activity for pseudomonal cover -> additional gram neg cover diff from backbone: AG/FQ 2. no MDRO risk factors 3. backbone tx: pip-tazo

Pharmacotherapy (10 decks)

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