Ventilator Associated Pneumonia

Question 1

Hospital Acquired Pneumonia (HAP)

Answer 1

pneumonia which occurs 48 hours or more after admission, which was not incubating at the time of admission

Question 2

Ventilator-Associated Pneumonia (VAP)

Answer 2

pneumonia which arises more than 48-72 hours after endotracheal intubation

Question 3

Diagnosis

Answer 3

• new guidelines suggest non-invasive sampling when possible
• If using invasive sampling: suggest that antibiotics be withheld rather than continued if quantitative culture results are below the diagnostic threshold for VAP (PSB < 1000 cfu/mL; BAL < 10,000 cfu/mL)
• if VAP is suspected the patient should get a blood culture

Question 4

Threshold values for cultured specimens:

Answer 4

everything is > 10^4 except:

• protected specimen brushing (PSB) - > 10^3
• NB-PSB - > 10^3
• Endotracheal aspirate (ETA) - > 10^5

Question 5

Risk Factors for MDR VAP

Answer 5

• Prior IV antibiotic use w/in 90 days
• Septic shock at time of VAP
• ARDS preceding VAP
• 5 or more days of hospitalization prior to occurence of VAP
• Acute renal replacement therapy prior to VAP onset

Question 6

Risk Factors for MDR HAP

Answer 6

• Prior IV antibiotic use w/in 90 days

Question 7

Risk Factors for MRSA VAP/HAP

Answer 7

Prior IV antibiotic use w/in 90 days

Question 8

Risk Factors for MDR Pseudomonas VAP/HAP

Answer 8

Prior IV antibiotic use w/in 90 days

Question 9

Empiric Antibiotic Therapy

Answer 9

Recommend coverage for S. aureus, P. aeruginosa, and other gram (-) bacilli in all empiric regimens

Question 10

When to suggest including an agent active against MRSA if any:

Answer 10

• MDR risk factor for antimicrobial resistance
• ICU MRSA prevalence > 10-20% of S. aureus
• Prevalence of MRSA is not known

Question 11

When to suggest prescribing 2 anti-pseudomonal antibiotics from different classes if any:

Answer 11

• MDR risk factor for antimicrobial resistance
• ICUs w/ > 10% of gram (-) isolates are resistant to an agent being considered for monotherapy
• ICU where local antimicrobial susceptibility rates unavailable

Question 12

Antibiotic Therapy for MRSA

Answer 12

• Recommend either vanc or linezolid

Question 13

Definitive Antibiotic Therapy for P. aeruginosa

Answer 13

• Recommend definitive therapy be based upon the results of antimicrobial susceptibility testing (strong rec)
• Recommend against aminoglycoside monotherapy (strong rec)
• No septic shock or not at a high risk for death: Recommend monotherapy using an antibiotic to which the isolate is susceptible rather than combination therapy (strong)
• Septic shock or at a high risk for death: suggest combination therapy using 2 antibiotics to which the isolate is susceptible rather than monotherapy (weak)

Question 14

Definitive Antibiotic Therapy w/ ESBL

Answer 14

• Recommend that the choice of an antibiotic for definitive therapy be based upon antimicrobial susceptibility testing & patient-specific factors (strong)

Question 15

Definitive Antibiotic Therapy for Acinetobacter spp.

Answer 15

• Suggest tx w/ either a carbapenem or ampicillin/sulbactam if the isolate is susceptible to these agents (weak)
• Recommend against the use of tigecycline
• Sensitive only to polymyxins: Recommend IV polymyxin (strong) & suggest adjunctive inhaled colistin (weak)

Question 16

Duration of Definitive Therapy

Answer 16

• Recommend a 7 day course of antimicrobial therapy rather than a longer duration(strong)

Question 17

Definitive Antibiotic Therapy for Carbapenemase producing organisms

Answer 17

• Recommend IV polymyxin (strong) & suggest adjunctive inhaled colistin (weak)