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Second Chance - HAP/VAP

What cultures should be collected?
Endotrachael aspirate - non-invasive
 
What organisms should always be covered?
S. aureus
Pseudomonas
Other gram negative bacilli
Risk factors for MDR VAP?
Prior IV abx within 90days
Concurrent septic shock
ARDS preceding VAP
5 or more days in hospital prior to VAP
Acute renal replacement tx prior to VAP
 
Risk Factors for MRSA VAP/HAP?
Prior IV abx within 90days
Concurrent septic shock
ARDS preceding VAP
5 or more days in hospital prior to VAP
Acute renal replacement tx prior to VAP
 
Risk Factors for MDR Pseudomonas VAP/HAP?
Prior IV abx within 90days
Concurrent septic shock
ARDS preceding VAP
5 or more days in hospital prior to VAP
Acute renal replacement tx prior to VAP
 
Institutional risk factor for MDRO for MRSA?
Unit where >10-20% of S. Aureus are MRSA
Unit where MRSA prevelance unknown
Institutional risk factor for MDRO for gram negative bacilli?
Unit where > 10% of gram (-) isolates are resistant to monotherapy
Unit where local susceptibility unknown
MSSA + double pseudomonas coverage include:
Pip/tazo
Cefepime
Meropenem
Imipenem
Aztreonam (not that great)
In addition to one other agent, what can be used for MSSA + pseudomonas coverage?
Levo/Cipro
AG
Colistin
What is the duration of therapy for VAP?
7 days
10 days
Toxicity to beta-lactams include:
Seizures
Acute interstitial nephritis
Toxicity to FQs include:
Tendon rupture
QTc prolongation
Peripheral neuropathy
For Klebsiella, what is the most narrow choice?
Cefazolin
Ceftriaxone
What if VAP diagnosed day 5 or later?
Add Vanco/Linezolid for MRSA coverage
 
Tx threshold for Klebsiella? If not above these, discontinue
BAL > 100,000
PSB > 10,000
If patient diagnosed with HAP, what organism is the likely cause?
S. aureus
Gram negative bacilli (Pseudomonas)
If patient is on SSRI, what drug should patient not be on?
Linezolid - serotonin syndrome
Vancomycin
VAP Prevention - Pharmacy perspective
Interrupt sedation daily
Elevate head of bed 30 degrees
Perform oral care with chlorhexidine daily
Can procalcitonin be used to determine if tx can be d/c'd?
Yes
No
If susceptibility grows pseudomonas, what do you do?
D/C all other abx and provide monotherapy for pseudomonas as long as no other RF
 
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