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Nosocomial Pneumonia (Treatment (Doses (ceftazidime 2 g IV q8h cefepime 2…
Nosocomial Pneumonia
Treatment
VAP
MDR risk factors
or
GNB >10% resistant to monotherapy
or
local antibiotic susceptibility not known
1st Antipseudomonal
: pip/tazo, cefepime, ceftazidime, imipenem, meropenem, aztreonam
2nd Antipseudomonal
: FQ (levo, cipro), AG (amikacin, gent, tobra), colistin or polymyxin B
Plus MRSA Coverage
: vanco or linezolid
No MDR risk factors
Less than 10-20% of
S. aureus
isolates are MRSA
Broad-Spectrum
: pip/tazo, levofloxacin, cefepime, imipenem, or meropenem
Greater than 10-20% of
S. aureus
isolates are MRSA
(or prevalence not known)
Broad-Spectrum
: pip/tazo, cefepime, ceftazidime, levo, cipro, imipenem, meropenem, aztreonam
Plus MRSA Coverage
: vanco or linezolid
HAP
High mortality risk or IV antibiotics within 90 days?
Yes
One
: pip/tazo, cefepime, ceftazidime, imipenem, meropenem, aztreonam
Plus One
: FQ (levo, cipro), AG (amikacin, gent, tobra)
Plus One
: vanco or linezolid
No
See VAP w/o MDR risk factors
Duration of therapy
7 days for all patients?
Don't have to keep patient in hospital the entire time if clinically stable
Monitoring
Effectiveness
WBC count, fever, cultures
Drug-specific
Doses
ceftazidime 2 g IV q8h
cefepime
2 g IV q8h
levofloxacin
750 mg IV q24h
ciprofloxacin 400 mg IV q8h
piperacillin/tazobactam
4.5 g IV q6h
imipenem 500 mg IV q6h
meropenem
1 g IV q8h
vancomycin
15-20 mg/kg IV q8-12h
gentamicin 7mg/kg IV q24h
tobramycin 7mg/kg IV q24h
Etiology
Bugs
Enteric GNB (20-40%)
Staph. aureus
(20-30%)
Acenitobacter
(5-10%)
Legionella
(variable)
Risk factors: immunocompromised, diabetes, ESRD, lung disease, environmental factors
Anaerobes (
rare
; from significant aspiration)
People get spooked and jump to carbapenems and pip/tazo instead of cephs
Pseudomonas
(10-20%)
MDR risk factors (
VAP
)
Late onset
IV antibiotics within 90 days (
main risk factor for all NPs
)
Septic shock or ARDS
Acute renal replacement therapy
Cystic fibrosis:
Pseudomonas
more likely
Comorbid conditions
Symptoms
PE: fever, malaise, purulent sputum, cough
Labs: decreased O2 saturation, tachypnea
Definitions
Onset
Early onset
: within first 4 days of admission;
Abx-sensitive bugs more likely
Late onset
: 5+ days after admission;
MDR bugs more likely
Subtypes
HAP/VAP
HAP
: 48+ hours after hospitalization
VAP
: 48+ hours after ventilator use
HCAP
Healthcare-associated pneumonia: hospitalized for 2+ days within 90 days of infection; resides in LTC; received IV Abx or chemo; or would care, dialysis, etc.
Term removed from 2016 IDSA Guidelines
; focus on use of IV antibiotics