ID: nosocomial PNA

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ID: nosocomial PNA
2011-03-10 12:55:50
ID nosocomial PNA

ID: nosocomial PNA
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  1. HAP is pna that occurs ___h or more after admission, which was not intubated at the time of admin.
  2. VAP is pna that arises _____h after endotracheal intubation
    more than 48-72h
  3. after bacteria enters LRT and colonize, how do they overwhelm host defense system? (3)
    • mechanical: ciliated epithelium and mucus
    • humoral: antibody and complement
    • cellular: PMN, macrophage, lymphocyte, cytokine
  4. where do bugs come from?
    • Aspiration of oropharyngeal pathogens
    • Leakage of bacteria around the ET cuff
    • Colonization of ET with bacteria encased in biofilm resulting in embolization into the alveoli during suctioning or bronchoscopy
    • Stomach and sinuses: potential reservoirs
    • Hematogenous spread- less likely
  5. what are the risk factors for colonization?
    • severity of pt's underlying dz
    • prior surgery
    • exposure to abx
    • exposure to invasive resp devices and equipment
  6. HAP risk factors?
    • adv age (60yo)
    • comorbid dz (COPD)
    • previous abx tx
    • cardiothoracic or abd surgery
    • APACHE II >16
    • smoking
    • prior hospitalization or residency of LTC/NH
    • reflux
    • male
    • enteral feed
    • (slide 11)
  7. VAP risk factors? (slide 11)
    • supine position
    • comorbid dz (COPD)
    • previous abx
    • stress ulcer ppx with gastric pH changing meds (PPI; use H2block instead)
  8. general risk factors for HAP/VAP? (slide 12)
    • male sex
    • pre-existing pulm disease
    • multiple organ system fail
    • intubation
    • enteral feed
    • sepsis
  9. prefer which to reduce risk for HAP/VAP?
    oral endotracheal and orogastric tube vs. nasotracheal or nasogastric tube
    • oral!
    • nasal almost always has sinus infxn
  10. how do you reduce aspiration of oropharyngeal bacteria around the ET cuff? (slide 13) (3 ways)
    • limit the use of sedative and paralytic (b/c these limit cough/host-protective mechanism; paralytic also inc risk of VAP)
    • ET cuff pressure >20 cm H2O
    • continuous aspiration of subglottic secretion
  11. pt should be kept on what position to reduce risk?
    semi-recumbent (30-45o)
  12. which is preferred to reduce risk?
    enteral vs. TPN? how do they reduce risk
    • enteral
    • TPN inc risk for vascular infxn, esp fungemia
    • enteral reduce complication risk related to CVC (central venous catheter)
    • prevent reflux villous atrophy intestinal mucosa (this inc bacterial translocation)
  13. how does transfusion affect risk of HAP?
    • increases VAP risk
    • use prudently
  14. what stress ulcer meds can you use to prevent HAP risk?
    H2 blocker or sucralfate
  15. how should you control glucose in order to reduce risk for HAP/VAP?
    <150 mg/dL
  16. how do you control infection to prevent HAP?
    • alcohol based hand disinfection (wash hands for c.diff)
    • surveillance for local MDR
    • monitor and early removal of invasive device
    • program to reduce or alter abx practice
  17. early onset HAP/VAP happens in __ d of hospitalization. late onset happens __d or more.
    • first 4 days
    • 5 days or more
  18. are you supposed to treat early onset HAP and late onset similarly?
    • yes (slide 18)
    • treat as if resistant bug
  19. MDR risk factor:
    abx therapy in preceding __ days
  20. MDR risk factor:
    current hospitalization of __ days or more
    5 days
  21. HCAP risk factor:
    pt hospitalized in acute care hospital for __ or more days within ___days of infxn.
    • 2+ days
    • 90 days
  22. HCAP risk factor:
    received recent IV therapy, chemotherapy or wound care w/i the past __ days of the current infxn.
    30 days
  23. HCAP risk factor: T or F?
    attended a hospital or HD clinic.
  24. typical organisms for HAP? in the order of prevalence
    • s. aureus
    • enteric GN rods
    • streptococcus pneumoniae
    • pseudomonias spp
  25. clinical S&S of HAP?
    • new onset of fever
    • prulent sputum
    • leukocytosis
    • decline in oxygen
    • (+)cx for sputum or tracheal aspirate
    • BAL (104), PSB (103)
    • radiographic infiltrate that is new or progressive
  26. what 4 data does CPIS (clinical pulmonary infection score) combine to a numerical score? what score is infection?
    • clinical
    • radiographic
    • physiological (PaO2/FiO2)
    • microbiologic

    • CPIS >6 = infection
    • (slide 24)
  27. initial empiric abx therapy for early onset/ no MDR HAP?
    • ceftriaxone
    • or levo, moxi or cipro (FQ)
    • amp/sul
    • ertapenem
  28. initial empiric abx for late onset/ MDR risk HAP?
    • antipseudomonal cephalo (cefepime, ceftazidime)
    • antipsuedomonal carba (imi mero, dori)
    • b-lactam/b-lactam inhibitor (zosyn) + antipseudo FQ (levo, cipro) or AG (ami, gent, tobra)
    • or plus vanco/lin for MRSA
  29. why is AG maybe benefitial for initial empiric abx for late onset/MDR risk?
    AG is water loving so may benefit if bacteremia
  30. can you use daptomycin for MRSA risk empiric abx for late onset/MDR risk?
    • nope!!!
    • dapto is inactivated by lung surfactant so should not use in PNA
  31. initial IV adult abx for empiric tx of late onset/MDR risk HAP?
    • antipseudo cephalo (cefepime, ceftazidime)
    • carba (imi, mero)
    • zosyn
    • gent/tob/amik
    • antipseudo FQ (cipro, levo
    • )
    • vanc/lin
  32. which carbapenem has less seizure?
  33. unlike CAP dose, HAP dose for levo is?

    CAP is 500mg
  34. unlike CAP dose of 400mg q12h for cipro, HAP dose is?
    400mg q8h
  35. when GP HAP, should you use monotx or combo?
  36. when pseudo, should you use mono or combo tx ?
  37. whawt are some common monotx agents?
    • imi, mero
    • cefepime
    • zosyn
    • (slide 28)
  38. when GN HAP, should you use mono or combo tx?
    combo is better
  39. ___ and __ equal or exceed their serum concentration in bronchial secretion
    • FQ and linezolid
    • (slide 28)
  40. what agents to use for acinetobacter?
    • amp/sul
    • carba
    • colistin and polymyxin (but renal tox may be an issue so colistin aerosol can be an alt)
  41. what to use for ESBL enterobacteriaceae?
    • carbapenem , cefepime, zosyn
    • slide 29
  42. what to use for MRSA HAP?
    • lin, vanc
    • no dapto
    • (slide 29)
  43. duration of tx for VAP?
    6-8 days
  44. duration of therapy for CPIS <6 (which means no infection)?
    3 days
  45. when does resolution of HAP occur?
    48-72 h