Ios 10 Quiz 4 Kuma

Front 1

Hospital-acquired pneumonia (HAP)

Back 1

»Pneumonia that occurs 48 hours or more after admission, which was not incubating at the time of admission
»Replaces “nosocomial” pneumonia

Front 2

Ventilator-associated pneumonia (VAP)

Back 2

Pneumonia that arises more than 48-72 hours after endotracheal intubation

Front 3

if a patient comes into the hospital with CAP and needs ventilation, or if the had HAP and need ventialtion is that considered VAP

Back 3

nope

Front 4

Health-care associated pneumonia (HCAP)

Back 4

»Hospitalization for ≥2 days within preceding 90 days
»Resided in nursing home, extended care facility
»Received recent IV antibiotic therapy, chemotherapy, or wound care within 30 days
»Attended a hospital or hemodialysis clinic within 30 days

Front 5

The oropharynx and HAP

Back 5

Oropharynx of critically ill patients becomes heavily colonized by enteric gram-negative bacilli within 72 hours after admission
Microaspiration of secretions allows access of colonizing bacteria to lower airways
Many risk factors have been recognized
»Compromise of respiratory tract defense mechanisms
»Increased risk of aspiration

Front 6

how does ventilation increase the risk of getting pneumonia

Back 6

by-passing gag and cough defenses

Front 7

Risk Factors for Hospital-Acquired Pneumonia

Back 7

Severe illness (either acute or chronic)
Metabolic acidosis
Advanced age
Cigarette smoking
Prolonged hospitalization
Alcoholism
Major organ dysfunction
Coma
Nasogastric or endotracheal tubes
Malnutrition
Hypotension
Enteral feedings

Front 8

what drugs increase the risk for HAP

Back 8

sedatives, steroids and other immunosuppressive agents, antacids, histamine2-receptor antagonists

Front 9

why do antacids increase the risk for HAP

Back 9

because they neutralize the stomach acid so it is easier for the stomach to become colonized with the organisms that colonized the oropharynx

Front 10

Microbial Etiology of Hospital-Acquired Pneumonia

Back 10

Gram-negative bacilli50-70%
»Pseudomonas aeruginosa *
»Acinetobacter spp.
»E. coli
»Enterobacter spp.
»Klebsiella spp.
»Serratia spp.
»Anaerobes
»Legionella
Gram-positive cocci30-50%
»Staphylococcus aureus *
»Streptococcus pneumoniae

Front 11

what is the number 1 and 2 causes of HAP

Back 11

1. P. aeruginose
2., S. aureus (have to think about MRSA)

Front 12

Clinical Presentation of Hospital-Acquired Pneumonia

Back 12

Many signs/symptoms are similar to other types of pneumonia
Important indicators of infection in critically ill:
»New fever
»New leukocytosis
»Change in quantity or quality of sputum
»Worsening respiratory function
»Change in chest radiograph

look at the baseline and determine the changes from that point because these patients are typically being treated for something else to begin with

Front 13

goals of therapy of HAP

Back 13

»Resolution of clinical signs and symptoms
»Reduction in patient mortality
»Reduction in infection-related complications such as sepsis or seeding of other sites of infection through the bloodstream
»Avoidance of intolerable adverse effects and major drug toxicities
»Eradication of pathogenic microorganisms
»Minimization of the development of bacterial resistance
»Prevention of recurrence of the infection

Front 14

Nonpharmacologic therapy of HAP

Back 14

»Maintenance of respiratory function
–Supplemental oxygen
–Mechanical ventilation
»Adequate hydration
»Nutritional support (enteral or parenteral)
»Suctioning of secretions
»Chest physiotherapy

Front 15

Pharmacologic Treatment of Hospital-Acquired Pneumonia

Back 15

Antipyretics (APAP)
Bronchodilators and ipratropium (anticholinergic so drys up secretions)
Rapid empiric antibiotic therapy
»Obtain appropriate cultures before starting antibiotics
»Drug resistance is an important consideration
»Institutional-specific susceptibilities must be considered (if available)
»Broad spectrum coverage initially, narrow when additional information becomes available

Front 16

Risk Factors for Multidrug-Resistant (MDR) Pathogens in HAP/VAP

Back 16

Antimicrobial therapy in previous 90 days
Current hospitalization of ≥5 days
Immunosuppressive disease and/or therapy
Other factors:
»Hospitalization ≥2 days within preceding 90 days
»Resided in nursing home, extended care facility
»Home infusion therapy (including antibiotics)
»Chronic dialysis within 30 days
»Home wound care
»Family members with MDR pathogen

Front 17

Algorithm for Initiating Empiric Antibiotic Therapy for HAP, VAP, HCAP

Back 17

HAP, VAP, or HCAP suspected (all disease severity)---> late onset (>/= 5 days) or risk factor for MDR pathogens--->

NO: limited spectrum AB

YES: broad spectrum AB therapy for MDR pathogens (most patients fall into this category)

Front 18

Recommendations for Empiric Antimicrobial Therapy of HAP/VAP/HCAP: Early-onset (<5 days), no risk factors for multidrug-resistant (MDR) pathogens:

Back 18

»Ceftriaxone
»Respiratory fluoroquinolone
»Ampicillin/sulbactam

Front 19

Antibiotic Treatment:Patients at Risk for MDR BacteriaCombination

Back 19

TherapyAntipseudomonal cephalosporin (cefepime, ceftazidime) or
Antipseudomonal carbapenem*(imipenem or meropenem)orβ-lactam/ β-lactamase inhibitor (piperacillin-tazobactam)
+
Antipseudomonal fluoroquinolone (ciprofloxacin or levofloxacin)or Aminoglycoside (amikacin, gentamicin, or tobramycin)
+
Linezolid or Vancomycin†

Front 20

Empiric Antibiotics for Hospital-Acquired Pneumonia preferred therapy

Back 20

Antipseudomonal b-lactam+ aminoglycoside

Antipseudomonal b-lactam/b-lactamase inhibitor+ aminoglycoside

Antipseudomonal carbapenem + aminoglycoside

all can be with or without vanco

Front 21

Empiric Antibiotics for Hospital-Acquired Pneumonia alternative therapies

Back 21

Antipseudomonal b-lactam+ antipseudomonal fluoroquinolone

Antipseudomonal b-lactam/b-lactamase inhibitor+ antipseudom. FQ

Antipseudomonal carbapenem + antipseudomonal fluoroquinolone

Antipseudomonal fluoroquinolone + aminoglycoside

Aztreonam + aminoglycoside or antipseudomonal fluoroquinolone

all can be with or without vanco

Front 22

how many drugs are ususally in the regimen for VAP, HAP, HCAP

Back 22

3

Front 23

duration of treatment for HAP

Back 23

Typical duration of therapy = 14 days
»More severe infections may require 21 days or more
Clinical improvement should be seen within 48-72 hours
»Great variability in response to therapy

Front 24

are FQ a good antipseudomonal drug

Back 24

not really

Front 25

8 vs. 15 Days of Antibiotic TherapyVentilator-Associated Pneumonia

Back 25

Prospective, randomized, double-blind (until day 8) clinical trial
»51 French ICUs
Patients received mechanical ventilation for at least 48 hours
Drug selection based on discretion of treating physician
»Protocol specified adherence to ATS guidelines

Front 26

8 vs. 15 Days of Antibiotic TherapyVentilator-Associated PneumoniaChastre (primary outcome measure)

Back 26

»Death
»Microbiologically confirmed recurrence
»Antibiotic-free days assessed 28 days after first bronchoscopy for suspected onset of VAP

no sig. differnce in recurrences or mortalities

Front 27

Prevention of Hospital-Acquired Pneumonia

Back 27

Hand washing
Sitting upright and/or ambulation (decrease risk of aspiration)
Limit duration of mechanical ventilation
Limit manipulation of endotracheal tubes, catheters, etc.
Isolation of patients with multidrug-resistant pathogens
Selective digestive decontamination not recommended for most patients

Front 28

M.M. is a 38 y.o. male who was admitted to the trauma ICU after a serious motor vehicle accident. He was previously healthy with no significant PMH. This patient suffered multiple injuries and was placed on a mechanical ventilator for airway protection. On day #6 after admission M.M. develops fever, decreased oxygenation, new production of purulent secretions, and new infiltrates CXR. This infection would be classified as a:
1.Community-acquired pneumonia
2.Hospital-acquired pneumonia
3.Ventilator-associated pneumonia
4.Healthcare-associated pneumonia

Back 28

3.Ventilator-associated pneumonia

Front 29

M.M. is a 38 y.o. male who was admitted to the trauma ICU after a serious motor vehicle accident. He was previously healthy with no significant PMH. This patient suffered multiple injuries and was placed on a mechanical ventilator for airway protection. On day #6 after admission M.M. develops fever, decreased oxygenation, new production of purulent secretions, and new infiltrates CXR.
Organisms possibly associated with M.M.’s infection include:
1.Pseudomonas aeruginosaand Staphylococcus aureus
2.Enterobacter aerogenesand Klebsiella pneumoniae
3.Escherichia coliand Serratia marcescens
4.All of the above

Back 29

4.All of the above

Front 30

M.M. is a 38 y.o. male who was admitted to the trauma ICU after a serious motor vehicle accident. He was previously healthy with no significant PMH. This patient suffered multiple injuries and was placed on a mechanical ventilator for airway protection. On day #6 after admission M.M. develops fever, decreased oxygenation, new production of purulent secretions, and new infiltrates CXR.The most appropriate empiric antibiotic regimen for M.M.’s infection would be:
1.Ceftriaxone plus azithromycin
2.Cefepime plus clindamycin plus vancomycin
3.Ceftazidime plus gentamicin
4.Piperacillin/tazobactam plus ciprofloxacin plus vancomycin

Back 30

4.Piperacillin/tazobactam plus ciprofloxacin plus vancomycin

Front 31

M.M. is a 38 y.o. male who was admitted to the trauma ICU after a serious motor vehicle accident. He was previously healthy with no significant PMH. This patient suffered multiple injuries and was placed on a mechanical ventilator for airway protection. On day #6 after admission M.M. develops fever, decreased oxygenation, new production of purulent secretions, and new infiltrates CXR.
.
1.Aztreonam plus tobramycin plus vancomycin
2.Ciprofloxacin plus gentamicin
3.Aztreonam plus levofloxacin
4.Amikacin plus vancomycin

Back 31

1.Aztreonam plus tobramycin plus vancomycin

remember no cross-sensitivity with aztreonam