HAP/VAP

Question 1

What is Hosp-Acquired Pneumonia (HAP)?

Answer 1

Develops in hospitalised pts > 48h of admission

Resources:
A summary of the evidence and recommendations made in the ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia http://ow.ly/S3zA30iZfLa
ERJ Open Res 2018; 4: 00028-2018
https://doi.org/10.1183/23120541.00028-2018

Torres A, Niederman MS, Chastre J, et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia. Eur Respir J 2017; 50: 1700582 [https://doi.org/10.1183/13993003.00582-2017].

Question 2

What is Ventilator-assoc pneumonia (VAP)?

Answer 2

Occurs in pts who have received mechanical ventilation for ≥48h

Question 3

What are the common organisms in VAP/HAP

Answer 3

Early (<5d): S.pneumonia H.influenza, MSSA
Late (>5d): P.aeruginosa, Acinetobacter baumannii, MRSA, GNB

Question 4

What is the definition of GNB MDR in HAP/VAP

Answer 4

Resistant to ≥3 families of Abx

Question 5

What is the definition of high rate resistant pathogen in HAP/VAP?

Answer 5

Resistant is high when it exceeds ≥25%

Question 6

What are the features of high risk patients for VAP/HAP?

Answer 6

• Septic shock +/-
• Risk factors for MDR pathogens:
  1) Age ≥65
  2) AKI
  3) High rates of MDR pathogen (≥25% including gram -ve bacteria and MRSA)
  4) Prior use of Abx
  5) Recent prolonged hospitalisation (>5d)
  6) Previous colonisation by MDR

Question 7

What is the duration of Abx for HAP/VAP?

Answer 7

• 7-8d regimen in VAP with no immunodef, CF, other pulm prob (e.g. empyema, lung abscess, cavitation, necrotising pneumonia), with good response
• VAP/HAP with cavitation, or abscess, or necrotising characteristics, MRSA pneumonia, secondary bacteremia or concomitant endocarditis SHOULD BE excluded from short-course therapy
• Others:

Question 8

What is the Abx regimen for HAP/VAP?

Answer 8

• In low risk of MDR pathogen & ≤15% mortality risk –> monotherapy: Ertapenem/ Ceftriaxone/ Cefotaxime/ Moxifloxacin/ Levofloxacin
• In high risk MDR +/- >15% mortality risk –> depends if pt has septic shock or not:

If no septic shock: Single GNB +/- MRSA therapy
Options:
Need to be able to cover pseudomonas & MSSA (e.g. Imipenem, Meropenem, Cefepime, Tazocin, Levofloxacin, Ceftazidime).
If Aztreonam given, need to add another Abx covering MSSA (as Aztreonam only covers GNB)
MRSA coverage NEEDED to be given if the ICU has >25% MRSA resp isolates
Option: Vanc or Linezolid

If in septic shock: Dual GNB-pseudomonal coverage +/- MRSA therapy
Choose 1 for pseudomonal coverage: Imipenem, Meropenem, Cefepime, Tazocin, Ceftazidime, Aztreonam
+
Choose 1 for additional gram negative coverage: Aminoglycoside (e.g. Amikacin – preferred, Gentamicin, Tobramycin)
MRSA coverage needed to be given if the ICU has >25% MRSA resp isolates
Option: Vanc or Linezolid

Abx can be switched to monotherapy after 3-5d if:
1) Initial Rx was appropriate
2) Clinical improvement seen
3) C&S did not indicate XDR Gram negative bacteria/ CRE

If it did grow XDR/CRE–> combination Abx leads to lower mortality (e.g. Carbapenem + Colistin/ Tigecycline/ Gentamycin

Question 9

What is the greatest biomarker as the predictor of mortality in VAP/HAP?

Answer 9

• PCT at day 1 and day 4
• CRP also can be used. Decrease in either one is predictor of survival
• However PCT has limited value in renal failure, HD & resuscitated cardiac arrest