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HAP/VAP (Definitions (HAP (PNA occurring >48 hours after patient is in…

- - - - Unknown rate of MRSA in unit (no antibiogram)
      - Rate of MRSA > 10%
      - Pt received IV abx in last 90 days
    - - IV abx in last 90 days
      - Septic shock at time of VAP
      - ARDS preceding VAP
      - 5+ days of hospitalization prior to VAP
      - ARRT prior to VAP
      - Structural lung disease w/ hi-risk (CF, bronchiectasis)
      - 90% above PsA coverage do not need double coverage
    - - Vancomycin 15 mg/kg IV q8-12h
        
        Consider LD of 25-30 mg/kg for severe illness
        
        Monitoring required (tr goal 15-20)
        
        ADRs
        
        Flushing (Red Man Syndrome) w/ rapid infusion: slow down and/or use dph
        
        Nephrotoxicity: avoid other nephrotoxic agents (Bactrim)
      - Linezolid 600 mg IV q12h
        
        ADRs
        
        Serotonin syndrome: careful w/ concomitant SSRIs
        
        Dose-reduce SSRI
        
        Neuropathy
        
        thrombocytopenia
        
        Bacteriostatic: don't use for bacteremia w/ PNA
        
        Penetrates lung really well
      - Daptomycin - not recommended (doesn't penetrate lungs)
    - - Anti-pseudomonal penicillins
        
        pip-tazo 4.5 g IV q6h
      - Cephalosporins
        
        Ceftazidime 2g IV q8h
        
        Doesn't cover MSSA very well: DNU as monotherapy
        
        Cefepime 2g IV q8h
      - Carbapenems
        
        Imipenem 500 mg IV q6h
        
        Meropenem 1g IV q8h
      - Monobactams
        
        Aztreonam 2g IV q8h
    - - FQ
        
        cipro
        
        levo
      - Tobramycin
        
        DNU as monotherapy: doesn't penetrate lungs very well
        
        Use inhaled or nebulized
      - Avoid double B-lactams... want 2 different mechanisms
  - - - Yes
        
        2 anti-PsA, avoid 2 B-lactams
      - No
        
        1 of the following:
        
        Pip-Tazo 4.5 g IV q6h
        
        Cefepime 2g IV q8h
        
        Levo 750 mg daily
        
        Imipenem 500 mg IV q6h
        
        Meropenem 1g IV q8h
      - Defined as:
      - Not hi mortality risk, but risk of MRSA
        
        1 anti-PsA + 1 vanc/linzeolid
- - - - Used to differentiate between viral and bacterial infections, but guidelines recommend against it bc not a definitive marker
    - - Elevated lactate indicates lack of O2 perfusion to organs... body goes anaerobic and builds up lactate
    - - Non-invasive culture is recommended over invasive d/t safety. ideal sampling is endotracheal aspiration (least invasive)
        
        For patients who are not ventilated, do induced sputum sample
- - - - MRSA
      - PsA
      - MSSA
    - - S. pneumo
      - atypical