LRTI (Nosocomial Pneumonia - HAP/VAP) Flashcards
What are the risk factors for HAP/VAP?
Patient-related factors
- Elderly
- Smoking
- COPD, cancer, immunosuppression
- Prolonged hospitalization
- Coma, impaired consciousness (affect pt breathing and swallowing)
- Malnutrition (immunosuppression)
Infection control-related factors
- Lack of hand hygiene compliance
- Contaminated respiratory care devices (e.g., ventilator, intubation)
Healthcare-related factors
- Prior antibiotic use
- Sedatives (when pt are sedated, don’t breathe well, require supplemental O2, innate immunity down)
- Opioid analgesics
- Mechanical ventilation
- Supine position
How to prevent HAP/VAP?
- Practice hand hygiene
- Judicious use of antibiotics and medications with sedative effect
VAP specific:
- Limit duration of mechanical ventilation
- Minimize duration and deep levels of sedation
- Elevate head of bed by 30 degrees
- Identification of pathogens [HAP/VAP]
List the common causative pathogens
Pseudomonas Aeruginosa
Staphylococcus Aureus
Enteric gram-negative (Enterobacter, Klebsiella, E. Coli)
Acinetobacter spp.
Strenotrophomonas maltophilia
- Identification of pathogens [HAP/VAP]
Unlike CAP, HAP/VAP is not likely caused by ________
HAP/VAP not likely caused by:
- Streptococcus pneumoniae
- Haemophilus influenzae
- Atypicals
- Burkholderia pseudomallei
- Selection of antimicrobial and regimen [HAP/VAP]
At the minimum, empiric cover for HAP/VAP should cover?
- Pseudomonas Aeruginosa
- Staphylococcus Aureus
- Selection of antimicrobial and regimen [HAP/VAP]
HAP/VAP choice of antibiotics should be selected based on…?
- Local distribution of pathogens associated with HAP/VAP and their antimicrobial suscpetibilities
- ICU-specific antibiogram for VAP
- Empirically be able to cover Pseudomonas Aeruginosa and Staphylococcus Aureus
- Selection of antimicrobial and regimen [HAP/VAP]
In what situations would additional cover be needed (e.g., MRSA, ESBL producing gram-negative)
- MDRO risk factors
- Mortality risk factors (severely ill patients)
- Hospital or unit’s distribution of pathogen associated with HAP/VAP and their susceptibilities (antibiogram)
- Selection of antimicrobial and regimen [HAP/VAP]
Should empirically cover for MRSA if?
*MRSA risk factors
MRSA risk factors:
- Prior intravenous antibiotic use within 90 days
- Isolation of MRSA in last 1 year
- Hospitalization in a unit where >20% of S. aureus are MRSA
- Prevalence of MRSA in the hospital is unknown, but pt is at high risk for mortality (i.e. need ventilatory support due to HAP and septic shock)
- Selection of antimicrobial and regimen [HAP/VAP]
When is empiric double antipseudomonal antibiotic cover required?
*Pseudomonas aeruginosa risk factors (that require double cover)
Pseudomonas aeruginosa risk factors (that require double cover):
- Risk factor for antimicrobial resistance (e.g., prior intravenous antibiotic use within 90 days, isolation of P. aeruginosa in last 1 year, acute renal replacement therapy prior to VAP onset)
- Hospitalization in a unit where >10% of P. aeruginosa isolates are resistant to an agent being considered for monotherapy
- Prevalence of P. aeruginosa in the hospital is unknown, but pt is at high risk for mortality (i.e. need ventilatory support due to HAP and septic shock)
*The two agents should be from different class to ensure at least one is active against the bug
- Selection of antimicrobial and regimen [HAP/VAP]
In what situation can a single antipseudomonal agent be used for empiric cover?
Which agent must be AVOIDED as the sole antipseudomonal agent?
When the monotherapy considered has >=90% susceptibility
*Aminoglycoside CANNOT be used as monotherapy due to:
- Nephrotoxicity (many HAP/VAP patients in ICU are hemodynamically unstable, low BP can lead to reduced perfusion of the kidney and AKI)
- Low perfusion/distribution into lungs especially with abscess
(If used, at most 1 week)
- Selection of antimicrobial and regimen [HAP/VAP]
What is the general double antipseudomonal agent combination?
Beta-lactam + Fluroquinolone
OR
Beta-lactam + Aminoglycoside
- Selection of antimicrobial and regimen [HAP/VAP]
Name the antibiotic selection and their doses
Cover for:
Pseudomonas Aeruginosa
Staphylococcus Aureus
Enteric gram-negative (Enterobacter, Klebsiella, E. Coli)
Beta lactam
- IV Piperacillin/Tazobactam 4.5g q6-8h
- IV Cefepime 2g q8h
- IV Ceftazidime 2g q8h
- IV Meropenem 1g q8h
- IV Imipenem/Cilastatin 500mg q6h
AND/OR
- IV Levofloxacin 750mg q24h
- IV Ciprofloxacin 400mg q8-12h / PO 500mg q12h
- IV Amikacin 15-20mg/kg q24h
- IV Gentamicin 5-7mg/kg q24h
If MRSA risk factors, ADDITIONAL:
- IV Vancomycin 25-30mg/kg LD, 15mg/kg q8-12h, to achieve AUC/MIC 400-600
- IV/PO Linezolid 600mg q12h
*Avoid use of Ceftazidime or Ciprofloxacin, if theres no MRSA cover with Vanco/Linezolid (bc these two agents need Vanco/Linezolid to help cover MSSA)
- Selection of antimicrobial and regimen [HAP/VAP]
Why is Meropenem the last line Beta-lactam?
No need broad spectrum Carbapenem to cover ESBL-producing enteric GNR (unless there is MDRO risk, that require double cover)
Hence, okay to use Pip-Tazo/Cefepime/Ceftazidime first as single agents
- Selection of antimicrobial and regimen [HAP/VAP]
Discuss when and how deescalation / IV to oral conversion of CAP antibiotic regimen can be done
When to de-escalate?
- Pt is hemodynamically stable
- Pt has improved clinically
- Pt able to ingest oral medication
How to de-escalate?
=>Postive culture
- Use AST to guide selection of narrower spectrum and/or PO antibiotics
- For P. aeruginosa, SWITCH to SINGLE antipseudomonal agent based on AST
=> If no positive culture
- De-escalate but maintain cover according to local HAP/VAP antibiogram
- If antibiogram not available, then minimally cover for P. aeruginosa, enteric GNR, MSSA (can remove MRSA cover - may do MRSA screening)
- De-escalation is NOT possible for pt with significant risk for MDRO (still need MRSA, keep empiric for 7 days)
- IV to oral (either Cipro + Augmentin or Levo) (*Augmentin to cover MSSA)
- Selection of antimicrobial and regimen [HAP/VAP]
What is the treatment duration for HAP/VAP?
7 days recommended regardless of pathogen (*no diff in recurrence and mortality b/w short 7d and long course 8-14d)
*Provided pt achieved clinical stability:
- Resolution of vital signs abnormalities
- Baseline mental status for HAP (*VAP sedated, unable to assess)
*Most patient should achieve clinical stability within first 48-72h
