HAP/VAP

1. Differentiate between hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and ventilator-associated tracheobronchitis (VAT)

2. Identify patients at risk for HAP mortality and at risk for HAP/VAP caused by multi-drug resistant (MDR) pathogens

3.  List the most common pathogens associated with HAP and VAP

4. Construct appropriate empiric antimicrobial regimens for HAP and VAP

learning Objectives

1. New OR progressive infiltrate on imaging

2. Evidence that the infiltrate is infectious in origin

   • Fever ( > 38°C)

   • Leukocytosis or leukopenia

   • Purulent secretions

   • Decline in oxygenation

Start EMPIRIC therapy!

What two criteria define pneumonia?

• Minimizing sedation

• Nutrition Support

What two components of Strategies used to minimize VAP, do pharmacists help with most?

noninvasive; Invasive

• Non-invasive (endotracheal aspiration)

• Invasive (bronchoalveolar lavage

We prefer ____ cultures vs _____ cultures when diagnosing HAP/VAP

• Pseudomonas

• Acinetobacter

• Klebsiella

• Proteus

• E.Coli

• Enterobacter

• Staph A (MSSA/MRSA)

Potential HAP/VAP pathogens

1. Start Empiric BROAD spectrum ABX

2. Assess for MRSA and start empiric MRSA therapy as needed

3. Assess for MDR gram-negative bacilli and start second gram-negative agent if needed

HAP/VAP regimens can have up to 3 ABX at one time

EMPIRIC HAP/VAP treatment STEPS (1-3)

• Cephalosporin

  • Cefepime

  • Ceftazidime

• Penicillin

  • Piperacillin-tazobactam

• Carbapenem

  • Meropenem

  • Imipenem-cilastatin

• Monobactam

  • Aztreonam

1st line EMPIRIC BROAD spectrum ABX to treat HAP/VAP (antipseudomonal)

• Fluoroquinolones 

  • Ciprofloxacin

  • Levofloxacin

• Aminoglycosides

  • Amikacin

  • Gentamicin

  • Tobramycin

• Colistin

DO NOT use Aminoglycosides OR Colistin ALONE

2nd line EMPIRIC BROAD spectrum ABX to treat HAP/VAP (non-beta-lactams)

• Ventilatory support for HAP

• Septic shock

HAP risk factors for Increased mortality

• IV antibiotics within the past 90 days

• High risk of HAP mortality

• Unit with >20% of Staphylococcus aureus isolates are methicillin resistant

• Unit in which the MRSA prevalence is unknown

• Colonization or recent infection with MRSA

HAP risk factors for MRSA

• IV antibiotics within the past 90 days

• High risk of HAP mortality

• Structural lung disease (ie: cystic fibrosis)

• Colonization or recent infection with  MDR gram-negative pathogen

HAP risk factors for MDR Pseudomonas and other GNR bacteria

• IV antibiotics use within the previous 90 days

• Septic shock at time of VAP

• Acute respiratory distress syndrome preceding VAP

• ≥5 days of hospitalization prior to the occurrence of VAP

• Acute renal replacement therapy prior to VAP onset

VAP risk factors for MDR Pathogens

• Treatment in a unit with >10-20% of Staphylococcus aureus isolates are MRSA

• Treatment in a unit in which the MRSA prevalence is unknown

• Colonization or recent infection with MRSA

SPECIFIC VAP risk factors for MRSA

• Units where >10% GNR isolates resistant to monotherapy agent

• Unit where antimicrobial susceptibility is unknown

• Colonization or prior recent infection with  MDR gram-negative pathogen

VAP risk factors for MDR Pseudomonas and other GNR bacteria

400-600 mg*hr/L

Goal AUC for Vancomycin

• NO ANTIBIOTICS!!!!

How do we treat VAT?

NO!!!!

• Not since 2023

Are Inhaled ABX used in treatment of HAP/VAP?

• Carbapenem or Ampicillin/Sulbactam!!!

• DO NOT use tigecycline

• New agent: Sulbactam-durlobactam

When treating Acinetobacter species HAP/VAP, what are the specific/preferred treatments?

• Preferred antibiotic: Effective agent based on antimicrobial susceptibility testing (empiric options: ceftazidime-avibactam, ceftolozone-tazobactam, imipenem-cilastatin-relebactam, or meropenem-vaborbactam; may add second agent as well with different mechanism)

When treating carbapenem resistant pathogens species HAP/VAP, what are the specific/preferred treatments?

• Only used for specific scenarios with known history or current infection with a specific MDR pathogen

When Are NEWER Antimicrobials used to treat HAP/VAP?

• Clinical improvement

• Culture results

• Negative MRSA nasal swabs*

• Other patient-specific parameters

Deescalating therapy is based off of:

IF Positive cultures:

• Deescalate antibiotics based on cultures results and sensitivities; Add stop date

IF Negative cultures:

• If CXR positive: Consider stop dates

• If CXR negative: Consider discontinuing antibiotics

HAP/VAP treatment Deescalating pathway for clinical improvement after 48-72 hours

IF Positive cultures:

• Ensure appropriate antibiotics and doses; Search for other causes

IF Negative cultures:

• Search for other causes

HAP/VAP treatment Deescalating pathway for NO clinical improvement after 48-72 hours

7 days!!!

Duration of therapy for HAP/VAP treatment?

Patient characteristics;

• Patient hemodynamically stable

• Patient clinically improving

• Patient able to tolerate oral medications

Oral ABX selection:

• Oral antibiotic must have good lung penetration

• If pathogen identified, oral antibiotic therapy based on susceptibility results

• If pathogen not identified, oral antibiotic therapy based on appropriate de-escalation approach

Switching to oral ABX points after treating inpatient HAP/VAP