Lecture 45: Nosocomial Pneumonias: HAP and VAP

Hospital-Acquired Pneumonia (HAP)

denotes an episode of pneumonia not associated with mechanical ventilation

• a high clinical suspicion

• combined with bedside examination

• radiographic examination

• microbiologic analysis of respiratory secretions. (sputum for gram stain culture and sensitivity)

what is required for diagnosis fo HAP and VAP?

Ventilator-associated Pneumonia (VAP)

suspected when individual develops a:

• New or progressive infiltrate on chest radiograph

• Leukocytosis

• New fever

• Increase in Oxygen demand

• Purulent tracheobronchial secretions.

Clinical Pnuemonia Infection Score

(CPIS)

(for diagnosis of VAP)

-Enodtracheal Suction

-Bronchial Alveolar Lavage

how to obtain ventilator cultures

• Knowledge of organisms likely to be present

• Local resistance patterns within the ICU/ hospital

• A rational antibiotic regimen and a rationale for antibiotic de-escalation

Principles to apply when choosing appropriate therapy for VAP

Vancomycin and Zosyn

usual choices for antibitoic coverage in VAP

-Vancomycin

-Linezolid

Treatment for VAP:

-a gram positive antibiotic with MRSA activity

-Piperacillin-tazobactam

-Cephalosporins

-Carbapenems

-Monobactams

Treatment for VAP:

-gram negative anitbiotics with antipseudomonal activity: beta-lactam based agents

-Fluroquinolones

-Aminoglycosides

-Polymyxins

Treatment for VAP:

-gram negative antibiotics with antipseudomonal activity: non-beta-lactam based agents

Antibiograms

-data used to decrease unnecessary use of dual gram-negative and empiric methicillin-resistant MRSA antibiotic treatment

Antibiograms

example of what?

• either an antipseudomonal cephalosporin

• an antipseudomonal carbepenem

• or a β-lactam/β-lactamase inhibitor

empiric therapy for HAP

-Empiric Therapy

-Plus antipseuodomonal fluroquinolone, linezoid, or vancomycin

treatment for HAP

Rocephin (3rd generation Cephalosporin) and Zithromax (Macrolide)

treatment for HAP:

-inpatient with no risk factors

Rocephin (3rd generation Cephalosporin), Zithromax (Macrolide) and Vancomycin (MRSA coverage)

treatment for HAP:

-MRSA risk present

Zosyn (Penicillin with Beta Lactamase Inhibitor) and Levaquin (Fluoroquinolone)

treatment for HAP:

-pseudomonas risk present

Unasyn (Penicillin) or Zosyn (Penicillin with Beta Lactamase Inhibitor) or Augmentin (Penicillin) or Clindamycin (Lincosamide)

treatment for HAP:

-aspiration risk concern

Lung Abscess

-tissue necrosis

-cough with purulent sputum

-usually via an anaerobic infection

-gram negative robs in debilitated pts

Lung Abscess

Light's Criteria

-for differentiating transudates from exudates in pleural effusion

Transudative

Conditions associated

with ___________ pleural effusions:

• Congestive Heart Failure (CHF)

• Hepatic cirrhosis

• Hypoproteinemia

• Nephrotic syndrome

• Acute atelectasis

• Myxedema

• Peritoneal dialysis

• Meig's syndrome

• Obstructive uropathy

• End-stage renal disease

Exudative

Conditions associated

with ___________ pleural effusions:

•Malignancy

•Infection

•Trauma

•Pulmonary infarction

•Pulmonary embolism

•Autoimmune disorders

•Pancreatitis

•Ruptured esophagus

•Rheumatoid Pleurisy

•Drug-induced Lupus

•Tuberculosis

Empyema

pus in the pleural cavity

-Antibiotic

-Drainage

-Chest tube plus streptokinase

treatment of Empyema