Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
ID Exam 4 B
Shah HAP and VAP
| Question | Answer |
|---|---|
| What is Dr. Shah's step-wise approach to nosocomial (hospital) pneumonia? | 1. Diagnose pneumonia 2. Determine risk for MRSA and PsA (Pseudomonal) 3. Empiric antibiotic therapy 4. Gather Data 5. Streamline therapy 6. Duration of tx |
| What do both HAP and VAP share? | Pathogens (similar), ABX options, Pathogen-specific tx, duration of therapy |
| Definition of HAP is? | occurring greater than or equal to 48 hours after hospital admission w/o intubation |
| Definition of VAP is? | occurring greater than or equal to 48 hours after endotracheal intubation |
| What is the pathogenesis of HAP? | Pathogens invade via LOWER respiratory tract; Aspirations via oropharyngeal secretions; Hematogenous spread (more rare for blood SEEDING into the lungs; more common for lungs to SEED into the blood rather than 🩸 into 🫁) Aspiration |
| What is the pathogenesis of VAP? | Pathogens invade via direct inoculation from biofilm formation or endotracheal tube |
| What are some non-specific clinical features? | cough +/- purulence; fever; chest pain; dyspnea; tachypnea and/or tachycardia; consolidations; increased O2 requirements |
| What are some differential diagnosis (non-specific) | Pulmonary embolism, pulmonary edema, viral or fungal pneumonia, aspiration pneumonitis, Atelectasis; Acute Respiratory Distress Syndrome (ARDS), Ventilator-associated tracheobronchitis |
| Pathogens involved in HAP include? | S. aureus, including MRSA; P. aeruginosa; Enterobacteriaceae (-) including ESBL and MDR bugs; Acinetobacter baumannii |
| Pathogens involved in CAP include? | Viruses, S. Pneumoniae, H. Influenzae, Atypicals (Mycoplasma pneumiae, Chlamydophilia, Legionella |
| General order of pathogen prevalence from most common to least common? | MSSA--> MRSA--> PsA--> Kleb pneumo = E. Coli---> Acinetobacter--> Serratia |
| Which pathogen is most common in nosocomial pneumonia? | Staph auerus (MSSA/ MRSA |
| Diagnosis for HAP or VAP includes looking at the _______ _________ (gold standard) | clinical criteria |
| What is included in the clinical criteria for HAP or VAP? | Decline in oxygenation (decompensation); new onset of fever; purulent sputum; Leukocytosis |
| When diagnosing pneumonia, what is not recommended to take into consideration? List them out | Biomarkers: (Procalcitonin (PCT), sTREM-1 (can give false positives); CRP (C-reactive protein) (can give false positives and negatives) |
| What is Procalcitonin (PCT) used for? | more used to de-escalate abx (if its (-) PCT, we can say "its probably not bacterial and we an take abx off slowly" PCT does help with duration because it will be a shorter duration if my PCT is (-) but will NOT be used for HAP/VAP |
| Data for PCT is stronger in _____ but should never be used in HAP/VAP | CAP *we dont trust PCT when it comes to HAP bugs |
| What other tools can be used for diagnosing HAP/VAP? | 1. Chest X-ray (to show radiologic evidence of pneumonia) will show any OPACITIES similar to CAP; 2. Blood Cultures (are recommended for ALL pts with suspected HAP or VAP, especially important in VAP where about 15% of pts have a concomitant bacteremia |
| Shah: We do want blood cultures because remember "the LUNGS can _____ inot the blood very easily so we want to make sure its not something more severe like bacteremia | SEED |
| Diagnostic measures from less invasive to more invasive--> | Sputum cultures--> Traceal aspirate--> Bronchoalveolar lavage (BAL)--> Protected specimen brush (PSB) |
| For diagnosis--> NON-invasive respiratory cultures recommended for all pts with suspected ____ or _____ | HAP; VAP |
| HAP diagnosis--> | spontaneous expectoration, sputum induction, nasotracheal suctioning |
| VAP diagonisis--> | spontaneous expectoration, sputum induction, nasotracheal suctioning PLUS endotracheal aspiration (b/c we already have a tube going to lungs) |
| According to the guidelines: studies have showed ____ _______ in clincal outcomes b/w invasive and non-invasive cutlures in pts with VAP | NO DIFFERENCE *so why risk performing an invasive when a non-invasive will work just fine |
| MRSA nares are a really reliable predictor for MRSA in the lungs, best way to utilize MRSA nares is to de-escalate: what did Shah want us to know? | Higher use of MRSA nares in HAP compared to VAP so the sensitivity for VAP is 40% but its 85% for HAP |
| Other note on MRSA nares (nasal swab used for abx stewardship tool): MRSA nares correlate better to a _______ infection than an actual lung infection | SSTI |
| Shah: Bottom line for MRSA nares in pneumonia--> Trust a ______ result to rule out MRSA pneumonia | negative |
| Caveat to MRSA nares: A positive MRSA nares ____ ____ mean MRSA pneumonia, as Staphylococcus aureus is a _____ colonizer of the lungs | Does not; normal |
| Clinical Pulmonary Infection score (CPIS) is ____ ____ anymore | not used |
| What is the big picture of HAP and VAP coverage? | Your either covering for MSSA and/or MRSA AND your either covering for PsA w/ single or double-agent **its your job to detemrine MSSA vs MRSA and single vs double PsA agents |
| Considering selection of Empiric therapy in HAP: determine whether mortality risk is high such as: | HAP that requires ventilator support due to pneumonia (*Note difference of this risk factor compared to VAP diagnosis); Presence of Septic Shock |
| What to choose if my pt is high risk for mortality in HAP? why? | If high--> cover MRSA and DOUBLE-cover PsA. Because pts at higher risk of death have a lower margin of error when determining empiric therapy. We need to right the FIRST TIME **3 agents for HIGH RISK (2PsA + 1 MRSA) |
| What are my risk factors for MRSA in HAP pts? | 1. IV abx use in prior 90 days 2. Tx in units where MRSA prevalence is > 20% or unknown |
| Example of MRSA prevalence is > 20%--> | Antibiogram shows Nafcillin (73% for S. Aureus coverage meaning at least 27% are MRSA meaning i have a greater than 20% MRSA prevalence |
| What are my risk factors for double PsA coverage aside from high risk of mortality (septic shock and ventilated HAP due to pnoeumonia)? | 1. IV abx in prior 90 days 2. Structural lung disease (Bronchoiectasis/Cystic fibrosis) |
| List out all 3 risk factors for when to administer double PsA coverage for HAP? | 1. High risk and mortality (septic shock and ventilated due to their pneumonia (either one of these will get double PsA) 2. other criteria: IV abx use in the past 90 daus (same risk factor for MRSA) but instead of the whole >20% risk factor, now I care about Structural damage 3. So if they have structural lung disease the 2 to be familiar with is bronchoiectasis and cystic fibrosis |
| High mortality risk includes? What agents do we use? | Ventilation due to PNA and Septic Shock; MRSA + 2x PsA |
| MRSA risk factors include? What agents do we use? | IV antibiotics in past 90 days; MRSA > 20% or unknown; Add MRSA agent |
| Risk factors other than high risk mortality when you require Double PsA coverage? | IV antibiotics in past 90 days; Structural lung disease (cystic fibrosis and bronchiactesis |
| What are my MRSA abx agents? | Vancomycin, Daptomycin, Linezolid, TMP/SMX, Ceftaroline, Dalbavancin, Doxycycline, Clindamycin |
| What are my PsA abx agents? | Cefepime, Pip/Tazo, Carbapenems, Levofloxacin, Aztreonam, Aminoglycosides, Ceftaz/Avibactam (Avycaz), Ceftol/Tazo (Zerbaxa) |
| What are my empiric tx options for HAP? Pt is NOT at high risk for mortality and NO MRSA risk factors: what agents do we use? | Single agent for PsA PLUS MSSA agent *remember high risk: septic shock and ventilation due to pneumonia *2 MRSA risk factors are: IV abx use in last 90 days; MRSA prevalence > 20% *Don't need MRSA but i still need MSSA and 1 agent for PsA (potentially 1 agent will cover both PsA and MSSA |
| What are my empiric tx options for HAP? Pt is NOT at high risk for mortality but with MRSA risk factors: what agents do we use? | Single agent for Pseudomonas PLUS MRSA agent *not septic shock or vented byt they do have MRSA risk factors -they do have MRSA prevalence >20%; not high risk so single PsA, but now we need a MRSA agent. MSSA will not cut it because pt has MRSA risk factors |
| What are my empiric tx options for HAP? Pt has high risk for mortality OR Receipt of IV abx w/in 90 days or structural lung disease: what agents do we use? | Double agent for PsA PLUS MRSA agent *more severe pt |
| What drugs do we use for pt NOT at high risk for mortality and NO MRSA risk factors? | Pip-tazo and Cefepime; Levofloxacin; Imipenem and Meropenem *remember cipro doesnt cover any gram + |
| What drugs do we use for pt NOT at high risk for mortality but WITH MRSA risk factors? | PsA agent: (Pip-tazo, Cefepime, Ceftriaxone, Imipenem, Meropenem, Aztreonam, Levofloxacin, Ciprofloxacin) PLUS MRSA agent (Vancomycin, Linezolid) |
| What drugs do we use for pt at High Risk for mortality or Receipt of IV abx w/in 90 days or structural lung disease? | Pip-Tazo, Cefepime, Ceftazidime, Aztreonam, Imipenem or meropenem PLUS Cipro or Levofloxacin or Tobramycin PLUS MRSA agent (Vancomycin or Linezolid) |
| What are Shah's key points to know for HAP (And VAP)? | MRSA and double PsA therapy only applies to empiric therapy; Once we have cultures and susceptibilities, empiric therapy goes out the window and we treat what specifically to what is growing |
| Shah examples: Once cultures come back, "I don't care about double PsA coverage if I already know that its MRSA in the lungs--> can D/C all my PsA agents and just keep on ______ agents | MRSA |
| Shah example: If its PsA in the lungs, then I can D/C my vanco and pick up my PsA agents such as keeping ________ on for the whole duration | Cefepime |
| What is the duration of treatment for HAP and VAP? | 7 days (minimum) |
| When is day 1 of tx for HAP and VAP? | First day of pathogen-susceptible therapy |
| What is VAP? | Ventilator-associated Pneumonia |
| What is mechanical ventilation? | the use of machines to assist or replace the body's natural breathing process; used to support or maintain adequate oxygenation and carbon dioxide removal in pts who are unable to breathe adequately on their own |
| FYI: Definition of Invasive mechanical ventilation | involves artificial airways, including endotracheal tubes, which go through the mouth into the trachea=, and tracheostomy tubes, which go through a surgically created opening on the front of the neck called a tracheotomy |
| FYI: Definition of Non-invasive mechanical ventilation | Uses nasal plugs, face masks, or helmets to deliver positive pressure into the airways and force them open; includes continuous positive airways pressure (CPAP), which delivers the same amount of pressure in both inspiration and expiration, and bilevel positive airway pressure (BiPAP), which delivers two different amounts of pressure |
| What are my VAP risk factors? | Age greater than 60 yo; Higher APACHE II or SAPS II score (scoring tools to measure mortality); Malnutrition; Acute respiratory distress syndrome (ARDS); Burns; Recent abdominal or thoracic surgery; multi-organ failure; Low Glasgow Coma Scale (GCS) score |
| What are my other VAP risk factors? | Prior abx therapy; elevation in gastric pH; large volume aspiration; use of NG tube; prologned sedation and paralysis; supine position in bed; use of TPN instead of enteral nutrition; Repeated reintubation |
| Multi-drug resistant organisms (MDROs) are bacteria that have become ________ to certain abx | resistant |
| Common bugs that can show MDR resistance are S. aureus (MRSA), _______, _____________ -_____________ Enterobacteriaceae (CRE), carbapenem-resistant A. baumannii (CRAB), __________ | ESBL, carbapenem-resistant; Pseudomonas |
| What is my drug of choice for confirmed MDRs? | carbapenems |
| What are my newer abx for MDR pathogen treatment? | Avycaz, Zerbaxa, Fetroja, Vabormere *(Know that these drug options exist) |
| What are my risk factors for MDROs? | Prior IV abx use w/in 90 days; septic shock at time of VAP (*not when they come in ED, but septic shock after vented and greater than 2 days); ARDS preceding VAP; >/= 5 days of hospitalization prior to occurrence of VAP; Acute RRT prior to VAP onset |
| My risk factors for MRSA in VAP include: MDR VAP risk factor and tx in units where MRSA prevalence > 20% or unknown. What are my MDR VAP risk factors? | Prior IV abx use w/in 90 days; septic shock (*at time of VAP); Acute respiratory distress syndrome (ARDS) preceding VAP; >/= 5 days of hospitalization prior to occurrence of VAP; Acute RRT prior to VAP onset (*have one of these? we worry about MRSA) |
| The difference in risk factors between MRSA and PsA are the same in regards to MDR VAP risk factors (prior IV abx w/in 90 days; septic shock at time of VAP; ARDS preceding VAP; >/= 5 days of hospitalization prior to occurrence of VAP; Acute RRT prior to VAP onset) but what is the key difference with PsA risk factors? | Treatment in units where gram (-) bacilli resistance (GNB-R) >10% or unknown |
| Instead of structural lung disease and all that, I'm worried about gram (-) bacilli resistance in my VAP pts for PsA risk factors--> We see a similar concept | So we see a similar concept to where MRSA resistance comes in, but now I want to know how resistant is my gram (-) bacilli so cut off for this is 10% but remember that MRSA is 20% |
| Shah example: how do you know if GNB-R is >10%? look at Pip-tazo with a 86% coverage of PsA--> | 100-86= 14% (greater than 10% so this would require DOUBLE PsA coverage |
| Shah example: Cefepime coverage is 91% meaning: | Less than 10% resistance so single coverage is acceptable |
| Summary of VAP risk factors that require MRSA coverage includes? | MDR VAP risk factors; MRSA > 20% or unknown **Add MRSA agent |
| Summary of VAP risk factors that require double (2xPsA) coverage includes? | MDR VAP risk factor; GNB-R > 10% or unknown **Add 2 PsA agents |
| Shah special key point: If pt don't meet any of these VAP risk factors (MDR VAP risk factor; MRSA > 20% or unknown or GNB-R > 10% or unknown) but the MRSA is 30%--> what do i use to treat? | I only need a MRSA and a single PsA agent (concept is the same wehre the backbone is MSSA and 1 PsA and your determining if we need to escalate the MSSA to MRSA and if we need a 2nd PsA agent |
| Empiric tx for VAP with no MDR risk factors and low GNB-R: (Local MRSA <20% and GNB-R <10%) my tx options are? | Single agent for Pseudomonas and cover MSSA (*could use 1 drug to kill 2 bugs) |
| Empiric tx for VAP with no MDR risk factors and low GNB-R: (Local MRSA >20% or unknown and GNB-R <10%) my tx options are? | Single agent for Pseudomonas and cover MRSA (2 agents 1 PsA + 1 MRSA) |
| Empiric tx for VAP with no MDR risk factors and low GNB-R: (Local MRSA <20% and GNB-R <10%) my drug agents are? | Beta lactams (Pip-tazo, cefepime, imipenem, Meropenem); OR FQ (Levofloxacin) **Ensure agent is active against MSSA |
| Empiric tx for VAP with no MDR risk factors and low GNB-R: (Local MRSA >20% or unknown and GNB-R <10%) my drug agents are? | Beta lactams: (Pip-tazo, cefepime, Imipenem, Meropenem, Aztreonam) OR FQ (Levofloxacin or Ciprofloxacin) PLUS (Vancomycin or Linezolid) |
| Empiric tx for VAP with no MDR risk factors and HIGH GNB-R: (Local MRSA <20% and GNB-R >10% or unknown) my tx options are? | Double-cover for PsA; Cover MSSA |
| Empiric tx for VAP with no MDR risk factors and HIGH GNB-R: (Local MRSA >20% or unknown and GNB-R >10% or unknown) my tx options are? | Double-cover for PsA; Cover MRSA |
| Empiric tx for VAP with no MDR risk factors and HIGH GNB-R: (Local MRSA <20% and GNB-R >10% or unknown) my drug agents are? | Beta-lactams: (Pip-tazo, Cefepime, Imipenem, Meropenem, Aztreonam); FQ: Levofloxacin or Ciprofloxacin) **Provide double-coverage for PsA using 2 of the following from separate classes **Ensure at least 1 agent is active against MSSA **Remember Ciprofloxacin doesn't cover any gram (+) |
| Empiric tx for VAP with no MDR risk factors and HIGH GNB-R: (Local MRSA >20% or unknown and GNB-R >10% or unknown) my drug agents are? | Aminoglycosides (Amikacin, Gentamicin, Tobramycin); OR Polymixin (Colistin, Polymixin B) PLUS (Vancomycin or Linezolid) *remember that Polymixin B comes with lots of toxicities |
| Pathogen specific therapy: we start with Broad, empiric therapy using ________ _______ and _________ _________ , and source control and move towards narrow therapy | Culture data; Clinical Stability |
| Pathogen-specific therapy is ALWAUS based on _______ and ________ (C&S) report. Sometimes cultures do not grow anything or have mixed flora--> stuck with empiric treatment as long as pt is improving (tx for 7 days) | culture; susceptibility |
| Pathogen-specific therapy MRSA: Vancomycin dosing? ADRs? Clinical Pearls | +/- loading dose, 15-20 mg/kg IV q8-12h, goal trough 15-20 or AUC/MIC of 400-600; ADRs: Nephrotoxicity, infusion rxn; Clinical pearls: Renally adjusted GOLD standard, cheap, and tons of data *GOLD standard for MRSA |
| Pathogen-specific therapy MRSA: Linezolid dosing? ADRs? Clinical Pearls | 600 mg PO/IV q12h (FYI for dosing); ADRs: serotonin syndrome at day 1, thrombocytopenia at day 14 (can cause your platelets to tank); Clinical pearls: Bacteriostatic, only PO MRSA option with good data |
| Pathogen-specific therapy MRSA: Ceftaroline dosing? ADRs? Clinical Pearls | 600 mg IV q8-12h (FYI for dosing); ADRs: none really, neurotoxicity possible; Clinical pearls: Renally adjusted, not guideline recommended, not much data for Pneumonia |
| If having to choose b/w Vancomycin or Linezolid, we want to think about _________. If pt is having AKI, on _______, we may move towards LInezolid | toxicity; dialysis |
| Why isnt TMP-SMX not included for Pathogen-Specific therapy for MRSA? | Not used for MRSA tx (study found non-inferiority was not attained in comparison b/w TMP-SMX and Vanco |
| In comparison to Vanco vs Linezolid for MRSA therapy, the study found no difference in ___-day mortality. Both are equal but think about SE when choosing | 60-day mortality |
| Pathogen-specific therapy PsA tx: Cefepime Dosing? ADRs? Clinical Pearls? | 1-2g 8-12h infused over 30 min (FYI for dosing but remember infusion time); ADRs: CNS toxicity, C Diff. infection (CDI), hypersensitivity; Clinical Pearls: Renally adjusted, NO anaerobic coverage |
| Pathogen-specific therapy PsA tx: Pip-tazo Dosing? ADRs? Clinical Pearls? | 3.375-4.5g q6-8h infused over 4 hours (FYI for dosing but remember infusion time); ADRs: Nephrotoxicity (especially added w/ Vanco), neutropenia, hypersensitivity; Clinical Pearls: Renally adjusted, LONG infusion time for OPTIMAL PK killing |
| Pathogen-specific therapy PsA tx: Carbapenems Dosing? ADRs? Clinical Pearls? | Meropenem: 1-2g q8h over 30 min (FYI for dosing but remember infusion time); ADRs: CNS toxicity (imipenem is the worst), CDI, hypersensitivity, **Carbapenems worsen or cause seizures in pts w/ history of seizures; Clinical Pearls: Renally adjusted, best option for MDR especially ESBL |
| Pathogen-specific therapy PsA tx: Aminoglycosides Dosing? ADRs? Clinical Pearls? | Dosing varies --> all weight based TDM based on peaks and troughs; ADRs: NEPHROTOXICITY (very bad), ototoxicity, neurotoxicity, neuromuscular blockade, many more; Clinical Pearls: Renally adjusted, do not use mono-therapy for HAP or VAP *We don't want to use them by themselves, so don't choose Tobramycin as sole PsA agent, choose Pip-tazo or Cefepime or something with more data then add Tobra as 2nd PsA agent |
| Pathogen-specific therapy PsA tx: FQs Dosing? ADRs? Clinical Pearls? | Cipro: 500 mg q8-12h IV/PO or Levo: 750 mg IV/PO daily; ADRs: LOTS (tendon rupture, photosens., QTC prolong., GI disturbances, peripheral neuropathy, MG exacerbations, etc; Clinical Pearls: Renally adjusted, ONLY PO option for PsA coverage **good point on only PO option if a pt wants to go home |
| Pathogen-specific therapy PsA tx: Aztreonam Dosing? ADRs? Clinical Pearls? | 2g IV q8h (FYI for dosing); ADRs: Neutropenia, acute liver injury (ALI), injection site pain; Clinical pearls: Renally adjusted, safe option in beta-lactam allergy |
| Pathogen-specific therapy Acinetobacter spp tx: Ampicillin-Sulbactam Dosing? ADRs? Clinical Pearls? | 1.5-3g IV q6h (FYI for dosing) Can push higher doses (12g/day), cannot use PO AUGMENTIN as step-down for Acinetobacter spp.; ADRs: Injection site pain, rash, diarrhea; Clinical Pearls: Renally adjusted, Sulbactam component is the active component against Acinetobacter spp *Sulbactam does the killing which is why we can't use the Augmentin |
| Pathogen-specific therapy Other options for Acinetobacter spp tx includes which drugs? | Carbapenems (not Ertapenem); FQ; TMP-SMX--> weight-based dosing |
| When looking at VAP prevention options, we need to look at their risk factors and countering them with ________ _______ | preventative measures |
| VAP prevention--> risk factor of Intubation, preventative measure? | Use non-invasive ventilation |
| VAP prevention--> risk factor of Re-intubation, preventative measure? | Avoidance, careful extubation |
| VAP prevention--> risk factor of Nasotracheal intubation, preventative measure? | Orogastric intubation |
| VAP prevention--> risk factor of Aspiration, preventative measure? | Head of bed at 3-45 degrees; limit use of sedatives and paralytics; Avoid PPIs and H2RAs (gastric pH) *help prevent asiprations when your laying down pt |
| VAP prevention--> risk factor of Pharmacologic paralysis, preventative measure? | Avoid muscle relaxants |
| VAP prevention--> risk factor of Daily change of circuits, preventative measure? | Changed weekly (tubes that connect the mouth to machine--> possibility of introducing bacteria |
| VAP prevention--> risk factor of Colonization, preventative measure? | Oral antiseptics (i.e. chlorohexedine mouth wash) |
| VAP prevention--> risk factor of General Prevention, preventative measure? | PPSV23/PCV13 vaccinations |
| Remember: what is the Duration of tx for HAP and VAP? | 7 days minimum for HAP and VAP; Day 1 is first day of pathogen-susceptible therapy; can extend duration based on clinical stability |
| Shah duration example: Pt w/ HAP was started on empiric abx on 09/28. Cultures were inconclusive due to mixed flora growth. Primary team wants to continue empiric abx regimen due to clinical improvement. What day should the pt's abx be stopped? | 10/04; remember 09/28 is Day 1 (count 7 days) |
Created by:
Xander635
Popular Pharmacology sets