LRTI: HAP and VAP

HAP

Pneumonia acquired ≥ 48 hours after hospital admission

VAP

Pneumonia acquired ≥ 48 hours after endotracheal intubation

S. aureus

E. coli

K. pneumoniae

Enterobacter

Acinetobacter

Pseudomonas

Etiology of HAP/VAP

1. Age > 60

2. Aspiration

3. COPD, ARDS, coma

4. Administration of antacids, H2RAs, PPIs

5. Supine position

6. Enteral nutrition, nasogastric tube

7. Reintubation, tracheostomy, or patient transport

8. Head trauma, ICP monitoring

9. MDR risk: IV antibiotic use within 90 days

Risk factors for HAP/VAP

1. New lung infiltrates + clinical features

2. Blood and sputum cultures for ALL patients

3. Non-invasive respiratory cultures for ALL patients

- spontaneous expectoration

- sputum induction

- nasotracheal suctioning

4. Bronchoalveolar lavage (BAL): invasive

Diagnosis of HAP and VAP

- need for ventilator support due to pneumonia

- presence of septic shock

What constitutes a high mortality risk when considering empiric therapy for HAP?

1. IV antibiotic use in the prior 90 days

2. Treatment in units where MRSA prevalence > 20% or unknown

3. Colonization with OR prior isolation (1 year) of MRSA

What factors identify a need for MRSA coverage in empiric HAP treatment?

1. IV antibiotic use in the prior 90 days

2. Structural lung disease: bronchiectasis, CF

3. Colonization with OR prior isolation (1 year) of MDR Pseudomonas or other GN bacilli

What factors identify a need for Pseudomonal coverage in empiric HAP treatment?

Select ONE drug:

- Cefepime

- Piperacillin-Tazobactam

- Imipenem-Cilastatin

- Meropenem

- Levofloxacin

Empiric therapy for HAP in patients with a low mortality risk AND no MDR risk factors AND no MRSA risk factors

Select ONE drug to cover Pseudomonas:

- Cefepime

- Ceftazidime

- Piperacillin-Tazobactam

- Imipenem-Cilastatin

- Meropenem

- Ciprofloxacin

- Levofloxacin

- Aztreonam

Select ONE drug to cover MRSA:

- Vancomycin

- Linezolid

- Televancin

Empiric therapy for HAP in patients with a low mortality risk AND no MDR risk factors, but present MRSA risk factors

Select TWO drugs to double cover Pseudomonas:

- Cefepime OR Ceftazidime

- Piperacillin-Tazobactam

- Imipenem-Cilastatin OR Meropenem

- Aztreonam

- Ciprofloxacin OR Levofloxacin

- Tobramycin, Gentamicin, OR Amikacin

**Do NOT overlap beta-lactams: beta-lactam + FQ or AG

**Aztreonam is mainly used for patients with a PCN allergy

Empiric therapy for HAP in patients with a low mortality risk AND no MRSA risk factors, but present MDR risk.

Select TWO drugs for double coverage of Pseudomonas:

- Cefepime OR Ceftazidime

- Piperacillin-Tazobactam

- Imipenem-Cilastatin OR Meropenem

- Aztreonam

- Ciprofloxacin OR Levofloxacin

- Tobramycin, Gentamicin, OR Amikacin

Select ONE drug to cover MRSA:

- Vancomycin

- Linezolid

- Televancin

Empiric therapy for HAP in patients with a HIGH mortality risk OR present MDR risk factors AND present MRSA risk factors.

1. IV antibiotic use in the prior 90 days

2. Hospitalization for ≥ 5 days prior to VAP

3. Septic shock at time of VAP onset

4. ARDS prior to VAP onset

5. Acute renal replacement therapy prior to VAP onset

**If a patient meets one of these risk factors, then they should be treated with a 3-antibiotic regimen

Risk factors for MDR VAP

1. IV antibiotic use in the prior 90 days

2. Treatment in a unit where MRSA prevalence is >10-20% or unknown

3. Colonization with OR prior isolation of MRSA

MRSA risk factors in VAP

1. IV antibiotic use in the prior 90 days

2. Treatment in ICU where GN isolate resistance >10% or unknown

3. Colonization with OR prior isolation of MDR Pseudomonas or other GN bacilli

Factors that require double Pseudomonal coverage in VAP

Select ONE drug:

- Cefepime

- Piperacillin-Tazobactam

- Iminipenem-Cilastatin

- Meropenem

- Levofloxacin

Empiric therapy for VAP in patients with no MDR VAP risk factors AND no GN-bacilli risk factors AND no MRSA risk factors

Select ONE drug to cover Pseudomonas:

- Cefepime

- Ceftazidime

- Piperacillin-tazobactam

- Imipenem-Cilastatin

- Meropenem

- Ciprofloxacin

- Levofloxacin

- Aztreonam

Select ONE drug to cover MRSA:

- Vancomycin

- Linezolid

- Telavancin

Empiric therapy for VAP in patients with no MDR VAP risk factors AND no GN-bacilli risk factors, but MRSA risk factors present

Select TWO drugs to double cover Pseudomonas:

- Cefepime OR Ceftazidime

- Piperacillin-Tazobactam

- Imipenem-Cilastatin OR Meropenem

- Ciprofloxacin OR Levofloxacin

- Tobramycin, Gentamicin, OR Amikacin

- Aztreonam

Empiric therapy for VAP in patients with no MDR VAP risk factors AND no MRSA risk factors, but present GN-bacilli risk factors.

Select TWO drugs to double cover Pseudomonas:

- Cefepime OR Ceftazidime

- Piperacillin-Tazobactam

- Imipenem-Cilastatin OR Meropenem

- Aztreonam

- Ciprofloxacin OR Levofloxacin

- Tobramycin, Gentamicin, OR Amikacin

- Colistimethate OR Polymyxin B

Select ONE drug to cover MRSA:

- Vancomycin

- Linezolid

- Telavancin

Empiric therapy for VAP in patients with MDR VAP risk factors OR present GN-bacilli risk factors AND present MRSA risk factors.