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34 Cards in this Set

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What is Healthcare Associated Pneumonia?
1. In an acute care hospital for two or more days w/in 90 days of the infection.
2. I.V. antibiotic therapy, chemotherapy, wound care within 30 days.
3. attended a hospital or hemodialysis clinic.
How do patients get VAP
1. Bacterial entry to respiratory tract:
a. aspiration, leakage of secretions
2. Host and Tx related colonization.
3. Biofilm
4. Sources of Pathogens:
- healthcare devices, staff, enviroment.
What are some of the bacteria that can come from health care personnal:
- Staphylococci
- gram-negative bacteria (pseudomonas and acinetobacter spp)
Ventilator devices:
- staphylococci, enterobacteriae, legionella.
Faecal oral
enterobacteriaceae
What are some of the NON-MODIFYABLE risk factors for HAP?
- SEX
- underlying disease (COPD)
What are some of the modifyable risk factors?
- Body positioning
- Intubation/Mechanical Ventilation
- Concomitant use of antacids
- Enternal feedings
- Transfusion
- Hyperglycemia.
What is the onset of VAP/HAP?
Early-onset of VAP/HAP:
- first 4 days
- better prognosis
- usually antibiotic sensitive bacteria.
What is the late - onset of VAP/HAP?
- 5 days or more
- multi-drug resistnace pathogens
- increase morbidity or mortality.
What are some of the organisms that are related to HAP/VAP?
Gram Negative:
Serratia spp.
Pseudomonas spp.
Acinetobacter spp.
Citrobacter spp.
Enterobacter spp.
Gram (+): staph, strept, oropharyngeal (streptococcus viridans, coag (-) staphylococcus, corynebacterium)
Random pathogens that cause HAP/VAP
- Klebsiella
- H. influenza
- Stenotrophomonas
- Legionella
- Virus
- Fungus
Early onset of Nosocomial Pneumonia
S. pneumoniae
H. Influenza
S. aureus
Viruses
Late onset of nosocomial pneumonia.
Psuedomonas aeruginosa
MRSA and methicillin-sensitive
Aerobic gram - bacteria --> acinebacteriacae
- enterobacteriacae
Immunocompromised patients:
- stenotrophomonas
- fungus, viruses
What drugs have become resistant to psuedomonas, acinebacter, enterobacter, klebsiella?
1. Cephalosporins
2. Carbapenems
3. Fluoro
4. Amino
5. Piperacillin/Tazobactam
Risk factors for MDR pathogens:
1. Antimicrobial therapy in preceding 90 days.
2. Current hospitalization >= 5 days.
3. High freq. of antibiotic resistance in the community or specific hospital unit.
4. Presence of risk factors for HCAP
5. Immunosuppressive disease and/or therapy.
Diagnosis of VAP/HAP:

MUST HAVE: infiltrate + 1 or more of
1. New or progressive radiographic infiltrate.
2. Clinical findings of infection: new fever, purulent sputum, leukocytosis, decline in oxygenation.
3. w/o infiltrate on CXR = Tracheobronchitis.
What are some of the cultures that should be taken for VAP/HAP?
- Tracheal aspirate
- sputum: suctioned, bronchoalveolar lavage, protected brush specimen.
- blood cultures.
If an early onset of HAP, how do you treat it?
Zosyn or Rocephin + cleocin
Reaction to ceph or PCN:
GIVE CIPRO/LEVO + cleocin
MRSA: replace clin w/ vanco
Azithromycin or levo for atypicals.
What should be adjust renal dose for?
Cefepime
Ceftazidime
Imipenem
Meropenem
Zosyn
amino
Levo
Early onset of Nosocomial Pneumonia
S. pneumoniae
H. Influenza
S. aureus
Viruses
Late onset of nosocomial pneumonia.
Psuedomonas aeruginosa
MRSA and methicillin-sensitive
Aerobic gram - bacteria --> acinebacteriacae
- enterobacteriacae
Immunocompromised patients:
- stenotrophomonas
- fungus, viruses
What drugs have become resistant to psuedomonas, acinebacter, enterobacter, klebsiella?
1. Cephalosporins
2. Carbapenems
3. Fluoro
4. Amino
5. Piperacillin/Tazobactam
Risk factors for MDR pathogens:
1. Antimicrobial therapy in preceding 90 days.
2. Current hospitalization >= 5 days.
3. High freq. of antibiotic resistance in the community or specific hospital unit.
4. Presence of risk factors for HCAP
5. Immunosuppressive disease and/or therapy.
Diagnosis of VAP/HAP:

MUST HAVE: infiltrate + 1 or more of
1. New or progressive radiographic infiltrate.
2. Clinical findings of infection: new fever, purulent sputum, leukocytosis, decline in oxygenation.
3. w/o infiltrate on CXR = Tracheobronchitis.
What are some of the cultures that should be taken for VAP/HAP?
- Tracheal aspirate
- sputum: suctioned, bronchoalveolar lavage, protected brush specimen.
- blood cultures.
If an early onset of HAP, how do you treat it?
Zosyn or Rocephin + cleocin
Reaction to ceph or PCN:
GIVE CIPRO/LEVO + cleocin
MRSA: replace clin w/ vanco
Azithromycin or levo for atypicals.
What should be adjust renal dose for?
Cefepime
Ceftazidime
Imipenem
Meropenem
Zosyn
amino
Levo
Vancomycin
- TIME - DEPENDENT
- > 30 - 40 mcg/ml serum toxicity
Reasons for deterioration or nonresolution
1. No Pneumonia
2. Etiology not bacteria
3. Complicated pneumonia (absess
4. Resistant pathogen
5. Breakthrough infection
(too low dose)
How long should a patient be on antibiotics for AHP?
HAP: Antibiotic tx for 7 days., if fever persists up to 14 days.
psuedomonas: 14 days of antibiotic therapy.
Descalation Therapy:
narrow therapy to specific pathogen
Broad spectrum (
Cephalsporins (Cefepime, ceftazidime)
Carbepemems(Imipenem, Meropenem)
Betalactam/ase inhibitor:
piperacillin/tazobactam

PLUS: cipro/levo
or aminoglycoside (gentamicin, tobramycin, amikacin)

MRSA: VANCO, LINEZOLID
FLUOROQUINOLONE, AZITHRO --> FOR LEGIONELLA.