Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Pharmacotherapy > Nosocomial Pneumonia > Flashcards

Nosocomial Pneumonia Flashcards

1
Q

What is the definition of HAP (vocabulary)?

A

Onset 48 or more hours after hospital admission

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the definition of VAP (vocabulary)?

A

Onset 48 or more hours after mechanical ventilation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is the definition of CAP (vocabulary)?

A

Onset in the community or < 48 hours after hospital admission

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

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

A 
Elderly
Smoking
COPD, cancer, immunosuppression
Prolonged hospitalization
Coma, impaired consciousness
Malnutrition
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

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

A

Hand hygiene compliance

Contaminated respiratory care devices

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

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

A 
Prior antibiotic use
Sedatives
Opioid analgesics
Mechanical ventilation
Supine position
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

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

A

MSSA and Pseudomonas aeruginosa

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the mortality risk factors for HAP/VAP?

A

– Requiring mechanical ventilation as a result of HAP

– In septic shock

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
Q

How can we add empiric MRSA cover for HAP?

A

IV Vancomycin

IV Linezolid

26
Q

Which HAP patients require additional gram negative cover?

A

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
Q

How can we add additional empiric gram negative cover for HAP?

A

AGs: Gentamicin or Amikacin or Tobramycin
OR
FQs: Ciprofloxacin or Levofloxacin

*Ensure 2 different drug classes are chosen

28
Q

Why is ciprofloxacin used in providing additional gram negative cover in HAP?

A

Cipro provides excellent gram neg cover with lung penetration
- antipseudomonal agent from backbone can cover the gram pos that cipro cannot cover

29
Q

Which VAP patients require empiric MRSA cover?

A

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
Q

How can we add on empiric MRSA cover for VAP?

A

IV Vancomycin or IV Linezolid

31
Q

Which VAP patients require additional empiric gram negative cover?

A

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
Q

How can we add additional empiric gram negative cover in VAP?

A

AGs: Gentamicin or Amikacin or Tobramycin
OR
FQs: Ciprofloxacin or Levofloxacin

*Ensure 2 different drug classes are chosen

33
Q

What is the rationale for adding additional gram negative cover in HAP/VAP?

A

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
Q

Clinically, is there any difference between linezolid and vancomycin for MRSA cover in pneumonia?

A

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
Q

When should we de-escalate therapy in a HAP/VAP patient?

A

– 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
Q

How should we de-escalate therapy in a HAP/VAP patient when we have Positive blood and/or respiratory cultures?

A

Streamline to culture directed therapy

37
Q

How should we de-escalate therapy in a HAP/VAP patient when we have Negative blood and/or respiratory cultures?

A

De-escalate to backbone regimen (pseudomonas and MSSA cover)

- Remove MRSA/additional gram neg cover, if any

38
Q

What are the things to monitor for safety of tx?

A

– Adverse effects of antibiotics (e.g. diarrhea, rash)

– Renal function

39
Q

What are the clinical improvements we can expect from appropriate abx tx?

A

– 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
Q

What is the treatment duration of HAP/VAP?

A

7 days regardless of pathogen

41
Q

State the ROA, dose and frequency of Pip-tazo

A

4.5g IV q6-8h

42
Q

State the ROA, dose and frequency of Cefepime

A

2g IV q8h

43
Q

State the ROA, dose and frequency of Meropenem

A

1g IV q8h

44
Q

State the ROA, dose and frequency of Imipenem

A

500g IV q6h

45
Q

State the ROA, dose and frequency of Ciprofloxacin

A

400mg IV q8-12h

46
Q

State the ROA, dose and frequency of Levofloxacin

A

750mg IV q24h

47
Q

State the ROA, dose and frequency of Gentamicin

A

5-7mg/kg IV q24h

48
Q

State the ROA, dose and frequency of Amikacin

A

15mg/kg IV q24h

49
Q

State the ROA, dose and frequency of Vancomycin

A

15mg/kg IV q8-12h

50
Q

State the ROA, dose and frequency of Linezolid

A

600mg IV q12h

51
Q

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?

A

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
Q

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

A

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)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions