-
HAP is pna that occurs ___h or more after admission, which was not intubated at the time of admin.
48h
-
VAP is pna that arises _____h after endotracheal intubation
more than 48-72h
-
after bacteria enters LRT and colonize, how do they overwhelm host defense system? (3)
- mechanical: ciliated epithelium and mucus
- humoral: antibody and complement
- cellular: PMN, macrophage, lymphocyte, cytokine
-
where do bugs come from?
- Aspiration of oropharyngeal pathogens
- Leakage of bacteria around the ET cuff
- Colonization of ET with bacteria encased in biofilm resulting in embolization into the alveoli during suctioning or bronchoscopy
- Stomach and sinuses: potential reservoirs
- Hematogenous spread- less likely
-
what are the risk factors for colonization?
- severity of pt's underlying dz
- prior surgery
- exposure to abx
- exposure to invasive resp devices and equipment
-
HAP risk factors?
- adv age (60yo)
- comorbid dz (COPD)
- previous abx tx
- cardiothoracic or abd surgery
- APACHE II >16
- smoking
- prior hospitalization or residency of LTC/NH
- reflux
- male
- enteral feed
- (slide 11)
-
VAP risk factors? (slide 11)
- supine position
- comorbid dz (COPD)
- previous abx
- stress ulcer ppx with gastric pH changing meds (PPI; use H2block instead)
-
general risk factors for HAP/VAP? (slide 12)
- male sex
- pre-existing pulm disease
- multiple organ system fail
- intubation
- enteral feed
- sepsis
-
prefer which to reduce risk for HAP/VAP?
oral endotracheal and orogastric tube vs. nasotracheal or nasogastric tube
- oral!
- nasal almost always has sinus infxn
-
how do you reduce aspiration of oropharyngeal bacteria around the ET cuff? (slide 13) (3 ways)
- limit the use of sedative and paralytic (b/c these limit cough/host-protective mechanism; paralytic also inc risk of VAP)
- ET cuff pressure >20 cm H2O
- continuous aspiration of subglottic secretion
-
pt should be kept on what position to reduce risk?
semi-recumbent (30-45o)
-
which is preferred to reduce risk?
enteral vs. TPN? how do they reduce risk
- enteral
- TPN inc risk for vascular infxn, esp fungemia
- enteral reduce complication risk related to CVC (central venous catheter)
- prevent reflux villous atrophy intestinal mucosa (this inc bacterial translocation)
-
how does transfusion affect risk of HAP?
- increases VAP risk
- use prudently
-
what stress ulcer meds can you use to prevent HAP risk?
H2 blocker or sucralfate
-
how should you control glucose in order to reduce risk for HAP/VAP?
<150 mg/dL
-
how do you control infection to prevent HAP?
- alcohol based hand disinfection (wash hands for c.diff)
- surveillance for local MDR
- monitor and early removal of invasive device
- program to reduce or alter abx practice
-
early onset HAP/VAP happens in __ d of hospitalization. late onset happens __d or more.
- first 4 days
- 5 days or more
-
are you supposed to treat early onset HAP and late onset similarly?
- yes (slide 18)
- treat as if resistant bug
-
MDR risk factor:
abx therapy in preceding __ days
90days
-
MDR risk factor:
current hospitalization of __ days or more
5 days
-
HCAP risk factor:
pt hospitalized in acute care hospital for __ or more days within ___days of infxn.
-
HCAP risk factor:
received recent IV therapy, chemotherapy or wound care w/i the past __ days of the current infxn.
30 days
-
HCAP risk factor: T or F?
attended a hospital or HD clinic.
T
-
typical organisms for HAP? in the order of prevalence
- s. aureus
- enteric GN rods
- streptococcus pneumoniae
- pseudomonias spp
-
clinical S&S of HAP?
- new onset of fever
- prulent sputum
- leukocytosis
- decline in oxygen
- (+)cx for sputum or tracheal aspirate
- BAL (104), PSB (103)
- radiographic infiltrate that is new or progressive
-
what 4 data does CPIS (clinical pulmonary infection score) combine to a numerical score? what score is infection?
- clinical
- radiographic
- physiological (PaO2/FiO2)
- microbiologic
- CPIS >6 = infection
- (slide 24)
-
initial empiric abx therapy for early onset/ no MDR HAP?
- ceftriaxone
- or levo, moxi or cipro (FQ)
- amp/sul
- ertapenem
-
initial empiric abx for late onset/ MDR risk HAP?
- antipseudomonal cephalo (cefepime, ceftazidime)
- antipsuedomonal carba (imi mero, dori)
- b-lactam/b-lactam inhibitor (zosyn) + antipseudo FQ (levo, cipro) or AG (ami, gent, tobra)
- or plus vanco/lin for MRSA
-
why is AG maybe benefitial for initial empiric abx for late onset/MDR risk?
AG is water loving so may benefit if bacteremia
-
can you use daptomycin for MRSA risk empiric abx for late onset/MDR risk?
- nope!!!
- dapto is inactivated by lung surfactant so should not use in PNA
-
initial IV adult abx for empiric tx of late onset/MDR risk HAP?
- antipseudo cephalo (cefepime, ceftazidime)
- carba (imi, mero)
- zosyn
- gent/tob/amik
- antipseudo FQ (cipro, levo
- )
- vanc/lin
-
which carbapenem has less seizure?
mero
-
unlike CAP dose, HAP dose for levo is?
750mg
CAP is 500mg
-
unlike CAP dose of 400mg q12h for cipro, HAP dose is?
400mg q8h
-
when GP HAP, should you use monotx or combo?
mono
-
when pseudo, should you use mono or combo tx ?
combo
-
whawt are some common monotx agents?
- imi, mero
- cefepime
- zosyn
- (slide 28)
-
when GN HAP, should you use mono or combo tx?
combo is better
-
___ and __ equal or exceed their serum concentration in bronchial secretion
- FQ and linezolid
- (slide 28)
-
what agents to use for acinetobacter?
- amp/sul
- carba
- colistin and polymyxin (but renal tox may be an issue so colistin aerosol can be an alt)
-
what to use for ESBL enterobacteriaceae?
- carbapenem , cefepime, zosyn
- slide 29
-
what to use for MRSA HAP?
- lin, vanc
- no dapto
- (slide 29)
-
duration of tx for VAP?
6-8 days
-
duration of therapy for CPIS <6 (which means no infection)?
3 days
-
when does resolution of HAP occur?
48-72 h
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