Podcast
Questions and Answers
Which of the following is a likely organism responsible for both HAP and VAP?
Which of the following is a likely organism responsible for both HAP and VAP?
- Enterococcus faecalis
- Streptococcus pneumoniae
- Pseudomonas aeruginosa (correct)
- Escherichia coli
What is the minimum time after hospital admission used to classify pneumonia as hospital-acquired?
What is the minimum time after hospital admission used to classify pneumonia as hospital-acquired?
- 72 hours
- 24 hours
- 48 hours (correct)
- 12 hours
What is the typical duration of hospital stay prolongation associated with nosocomial pneumonia?
What is the typical duration of hospital stay prolongation associated with nosocomial pneumonia?
- Approximately 1 week
- Approximately 2 weeks (correct)
- Approximately 4 weeks
- Approximately 3 weeks
What is the most reliable method for diagnosing nosocomial pneumonia?
What is the most reliable method for diagnosing nosocomial pneumonia?
What is the recommended frequency for maintenance doses of vancomycin?
What is the recommended frequency for maintenance doses of vancomycin?
Which of the following may increase the risk for serotonin syndrome when administered with linezolid?
Which of the following may increase the risk for serotonin syndrome when administered with linezolid?
What is one of the most common adverse effects to monitor when using vancomycin?
What is one of the most common adverse effects to monitor when using vancomycin?
Which strategy is recommended to reduce antimicrobial resistance in the context of pneumonia treatment?
Which strategy is recommended to reduce antimicrobial resistance in the context of pneumonia treatment?
What is the typical duration for mechanical ventilation prolongation associated with nosocomial pneumonia?
What is the typical duration for mechanical ventilation prolongation associated with nosocomial pneumonia?
What is a common clinical sign used to assess the effectiveness of antibiotic treatment in pneumonia?
What is a common clinical sign used to assess the effectiveness of antibiotic treatment in pneumonia?
What is generally the same between organisms causing HAP and VAP?
What is generally the same between organisms causing HAP and VAP?
What is the primary use of colistin in treating pneumonia?
What is the primary use of colistin in treating pneumonia?
What is the best definition of Ventilator-Associated Pneumonia?
What is the best definition of Ventilator-Associated Pneumonia?
What is the primary advantage of combination therapy?
What is the primary advantage of combination therapy?
What is the purpose of empiric antibiotic treatment?
What is the purpose of empiric antibiotic treatment?
Which of the following is least likely to be a risk factor for MRSA?
Which of the following is least likely to be a risk factor for MRSA?
When should therapy be modified?
When should therapy be modified?
When are aminoglycosides NOT recommended?
When are aminoglycosides NOT recommended?
According to the guidelines, how should vancomycin dosing be monitored?
According to the guidelines, how should vancomycin dosing be monitored?
Why is daptomycin not recommended for treating pneumonia?
Why is daptomycin not recommended for treating pneumonia?
What factor influences whether to add MRSA coverage or double antipseudomonal coverage?
What factor influences whether to add MRSA coverage or double antipseudomonal coverage?
Which of the following infections prolongs ventilation?
Which of the following infections prolongs ventilation?
Which outcome is NOT affected by duration of the course of antibiotics?
Which outcome is NOT affected by duration of the course of antibiotics?
If a patient susceptible to polymyxin what should they be tested for?
If a patient susceptible to polymyxin what should they be tested for?
Which route of administration is used for Colistin?
Which route of administration is used for Colistin?
What should be used to determine the appropriate use of antibiotics locally?
What should be used to determine the appropriate use of antibiotics locally?
What is the main indication that procalcitonin can be used?
What is the main indication that procalcitonin can be used?
Which can be used in combination IV to treat Acinetobacter?
Which can be used in combination IV to treat Acinetobacter?
A VAP has all of the following EXCEPT
A VAP has all of the following EXCEPT
Which of the following is a risk factor for MDR
Which of the following is a risk factor for MDR
Which organism is the same for HAP and VAP?
Which organism is the same for HAP and VAP?
Is increased clinical cure rate and advantage or a disadvantage?
Is increased clinical cure rate and advantage or a disadvantage?
What is the name of an older antibiotic?
What is the name of an older antibiotic?
When could superinfections be increased?
When could superinfections be increased?
Are inhaled forms of newer antibiotics, aminoglycosides or polymyxins used frequently?
Are inhaled forms of newer antibiotics, aminoglycosides or polymyxins used frequently?
Which type of test is not recommended data included?
Which type of test is not recommended data included?
After how long should symptoms of Pneumonia be assessed?
After how long should symptoms of Pneumonia be assessed?
What should all patients always be receiving?
What should all patients always be receiving?
Which of the following should be completed regularly?
Which of the following should be completed regularly?
Is it better to rely on experience or rationals to follow?
Is it better to rely on experience or rationals to follow?
Which of the following is NOT a recommendation for Inhaled Antibiotics
Which of the following is NOT a recommendation for Inhaled Antibiotics
Which is considered off-label
Which is considered off-label
What is the key distinguishing factor between hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) in terms of their definitions?
What is the key distinguishing factor between hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) in terms of their definitions?
Compared to ventilator-associated pneumonia (VAP), hospital-acquired pneumonia (HAP) is typically associated with which of the following epidemiological characteristics?
Compared to ventilator-associated pneumonia (VAP), hospital-acquired pneumonia (HAP) is typically associated with which of the following epidemiological characteristics?
Which of the following statements accurately reflects the etiology of nosocomial pneumonia (HAP and VAP)?
Which of the following statements accurately reflects the etiology of nosocomial pneumonia (HAP and VAP)?
The diagnosis of nosocomial pneumonia is primarily based on:
The diagnosis of nosocomial pneumonia is primarily based on:
According to guidelines, what is the role of biomarkers such as procalcitonin (PCT) in the diagnosis of nosocomial pneumonia?
According to guidelines, what is the role of biomarkers such as procalcitonin (PCT) in the diagnosis of nosocomial pneumonia?
In the initial management of nosocomial pneumonia, determining mortality risk is crucial. Which of the following factors is considered a high mortality risk indicator?
In the initial management of nosocomial pneumonia, determining mortality risk is crucial. Which of the following factors is considered a high mortality risk indicator?
When selecting empiric antibiotics for nosocomial pneumonia, which of the following considerations is MOST important to guide the choice of therapy?
When selecting empiric antibiotics for nosocomial pneumonia, which of the following considerations is MOST important to guide the choice of therapy?
According to the general principles for treating nosocomial pneumonia, initial empiric antibiotic therapy should provide coverage for which of the following?
According to the general principles for treating nosocomial pneumonia, initial empiric antibiotic therapy should provide coverage for which of the following?
Therapy for nosocomial pneumonia should be modified based on:
Therapy for nosocomial pneumonia should be modified based on:
Which of the following is considered a risk factor for multi-drug resistance (MDR) in the context of ventilator-associated pneumonia (VAP)?
Which of the following is considered a risk factor for multi-drug resistance (MDR) in the context of ventilator-associated pneumonia (VAP)?
According to the empiric treatment guidelines for hospital-acquired pneumonia (HAP), monotherapy with a beta-lactam or fluoroquinolone is appropriate for patients with:
According to the empiric treatment guidelines for hospital-acquired pneumonia (HAP), monotherapy with a beta-lactam or fluoroquinolone is appropriate for patients with:
For a patient with ventilator-associated pneumonia (VAP) at high risk for multi-drug resistance (MDR), empiric antibiotic therapy should include:
For a patient with ventilator-associated pneumonia (VAP) at high risk for multi-drug resistance (MDR), empiric antibiotic therapy should include:
Which of the following is a recommended empiric antibiotic regimen for a patient with hospital-acquired pneumonia (HAP) who is at low risk for mortality but at high risk for MRSA?
Which of the following is a recommended empiric antibiotic regimen for a patient with hospital-acquired pneumonia (HAP) who is at low risk for mortality but at high risk for MRSA?
According to the provided information, what is a significant limitation associated with the ZEPHYR study comparing vancomycin to linezolid for MRSA pneumonia?
According to the provided information, what is a significant limitation associated with the ZEPHYR study comparing vancomycin to linezolid for MRSA pneumonia?
What is the recommended target AUC/MIC ratio for vancomycin in treating complicated Staphylococcus aureus infections, including pneumonia?
What is the recommended target AUC/MIC ratio for vancomycin in treating complicated Staphylococcus aureus infections, including pneumonia?
Which of the following is a common adverse effect associated with vancomycin administration that is NOT a true allergy?
Which of the following is a common adverse effect associated with vancomycin administration that is NOT a true allergy?
Why is daptomycin generally NOT recommended for the treatment of pneumonia?
Why is daptomycin generally NOT recommended for the treatment of pneumonia?
For definitive therapy of Pseudomonas aeruginosa pneumonia in a patient who is NOT in septic shock and whose isolate is susceptible, which of the following monotherapy options is recommended?
For definitive therapy of Pseudomonas aeruginosa pneumonia in a patient who is NOT in septic shock and whose isolate is susceptible, which of the following monotherapy options is recommended?
In the treatment of Pseudomonas aeruginosa pneumonia, when is combination therapy (two agents) recommended?
In the treatment of Pseudomonas aeruginosa pneumonia, when is combination therapy (two agents) recommended?
If a patient's Acinetobacter spp. pneumonia isolate is only susceptible to polymyxins, what is the recommended treatment strategy?
If a patient's Acinetobacter spp. pneumonia isolate is only susceptible to polymyxins, what is the recommended treatment strategy?
For carbapenem-resistant organisms, if the pneumonia isolate is only susceptible to polymyxins, the recommended treatment is:
For carbapenem-resistant organisms, if the pneumonia isolate is only susceptible to polymyxins, the recommended treatment is:
Which of the following newer drugs is indicated for hospital-acquired and ventilator-associated pneumonia (HAP/VAP) and is active against most ESBLs?
Which of the following newer drugs is indicated for hospital-acquired and ventilator-associated pneumonia (HAP/VAP) and is active against most ESBLs?
Which of the following statements correctly describes the renal elimination of colistin and polymyxin B?
Which of the following statements correctly describes the renal elimination of colistin and polymyxin B?
Which formulation difference exists between colistin (polymyxin E) and polymyxin B?
Which formulation difference exists between colistin (polymyxin E) and polymyxin B?
What is the primary clinical indication for using inhaled antibiotics in the treatment of nosocomial pneumonia?
What is the primary clinical indication for using inhaled antibiotics in the treatment of nosocomial pneumonia?
Which of the following inhaled antibiotics is NOT routinely recommended due to lack of sufficient clinical evidence?
Which of the following inhaled antibiotics is NOT routinely recommended due to lack of sufficient clinical evidence?
What is the recommended duration of antibiotic therapy for both hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) in most cases?
What is the recommended duration of antibiotic therapy for both hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) in most cases?
What is a potential benefit of using shorter courses (7-8 days) of antibiotic therapy compared to longer courses (10-15 days) for nosocomial pneumonia?
What is a potential benefit of using shorter courses (7-8 days) of antibiotic therapy compared to longer courses (10-15 days) for nosocomial pneumonia?
What is the primary goal of antibiotic de-escalation in the treatment of nosocomial pneumonia?
What is the primary goal of antibiotic de-escalation in the treatment of nosocomial pneumonia?
According to the guidelines, what is the role of procalcitonin (PCT) concentration in guiding antibiotic discontinuation for pneumonia?
According to the guidelines, what is the role of procalcitonin (PCT) concentration in guiding antibiotic discontinuation for pneumonia?
Which of the following is NOT considered a recommendation for the use of inhaled antibiotics in nosocomial pneumonia?
Which of the following is NOT considered a recommendation for the use of inhaled antibiotics in nosocomial pneumonia?
Which of the following statements is TRUE regarding the clinical evidence for inhaled antibiotics in nosocomial pneumonia?
Which of the following statements is TRUE regarding the clinical evidence for inhaled antibiotics in nosocomial pneumonia?
Which of the following antibiotic agents is considered an 'older drug' in the context of nosocomial pneumonia treatment strategies?
Which of the following antibiotic agents is considered an 'older drug' in the context of nosocomial pneumonia treatment strategies?
According to the lecture, relying solely on 'experience' in antibiotic stewardship is generally considered:
According to the lecture, relying solely on 'experience' in antibiotic stewardship is generally considered:
Which of the following is a potential disadvantage associated with the use of inhaled antibiotics?
Which of the following is a potential disadvantage associated with the use of inhaled antibiotics?
In which clinical scenario might superinfections be theoretically increased in the context of nosocomial pneumonia treatment?
In which clinical scenario might superinfections be theoretically increased in the context of nosocomial pneumonia treatment?
According to the lecture, what is the clinical significance of increased clinical cure rate as a potential advantage in antibiotic treatment?
According to the lecture, what is the clinical significance of increased clinical cure rate as a potential advantage in antibiotic treatment?
If a patient is susceptible to polymyxin antibiotics, what further testing should be considered according to the lecture content?
If a patient is susceptible to polymyxin antibiotics, what further testing should be considered according to the lecture content?
When should empiric antibiotic therapy for nosocomial pneumonia be modified or adjusted?
When should empiric antibiotic therapy for nosocomial pneumonia be modified or adjusted?
In which of the following scenarios are aminoglycosides generally NOT recommended as monotherapy for pneumonia?
In which of the following scenarios are aminoglycosides generally NOT recommended as monotherapy for pneumonia?
In a patient presenting with suspected nosocomial pneumonia, what is the MOST critical initial step in guiding treatment strategy?
In a patient presenting with suspected nosocomial pneumonia, what is the MOST critical initial step in guiding treatment strategy?
For a patient at low risk of mortality with hospital-acquired pneumonia (HAP), which empiric antibiotic regimen would be MOST appropriate according to guideline-based recommendations?
For a patient at low risk of mortality with hospital-acquired pneumonia (HAP), which empiric antibiotic regimen would be MOST appropriate according to guideline-based recommendations?
A patient with ventilator-associated pneumonia (VAP) is at high risk for multi-drug resistant (MDR) organisms. Which empiric antibiotic regimen provides the MOST appropriate and comprehensive coverage?
A patient with ventilator-associated pneumonia (VAP) is at high risk for multi-drug resistant (MDR) organisms. Which empiric antibiotic regimen provides the MOST appropriate and comprehensive coverage?
In a patient with suspected MRSA pneumonia, what factor would MOST strongly influence the decision to use linezolid over vancomycin?
In a patient with suspected MRSA pneumonia, what factor would MOST strongly influence the decision to use linezolid over vancomycin?
What is the MOST important consideration when using inhaled antibiotics as an adjunctive treatment for nosocomial pneumonia?
What is the MOST important consideration when using inhaled antibiotics as an adjunctive treatment for nosocomial pneumonia?
Which factor is MOST critical in determining the duration of antibiotic therapy for a patient with hospital-acquired pneumonia (HAP) who shows clinical improvement?
Which factor is MOST critical in determining the duration of antibiotic therapy for a patient with hospital-acquired pneumonia (HAP) who shows clinical improvement?
What is the PRIMARY goal of antibiotic de-escalation in patients treated for nosocomial pneumonia?
What is the PRIMARY goal of antibiotic de-escalation in patients treated for nosocomial pneumonia?
When considering the use of procalcitonin (PCT) to guide antibiotic discontinuation in a patient with pneumonia and also has COPD, what is the MOST significant limitation?
When considering the use of procalcitonin (PCT) to guide antibiotic discontinuation in a patient with pneumonia and also has COPD, what is the MOST significant limitation?
Which of the following statements BEST describes the clinical evidence supporting the use of inhaled antibiotics in nosocomial pneumonia?
Which of the following statements BEST describes the clinical evidence supporting the use of inhaled antibiotics in nosocomial pneumonia?
In the treatment of nosocomial pneumonia, which of the following antibiotic stewardship practices is MOST likely to be effective?
In the treatment of nosocomial pneumonia, which of the following antibiotic stewardship practices is MOST likely to be effective?
In a patient at risk for multi-drug resistant (MDR) organisms, development of VAP, and septic shock, what is the BEST empiric treatment approach?
In a patient at risk for multi-drug resistant (MDR) organisms, development of VAP, and septic shock, what is the BEST empiric treatment approach?
Which of the following carbapenem-sparing options would be appropriate for treatment in confirmed pneumonia where the causative organism produces extended-spectrum beta-lactamases (ESBL)?
Which of the following carbapenem-sparing options would be appropriate for treatment in confirmed pneumonia where the causative organism produces extended-spectrum beta-lactamases (ESBL)?
When should use of inhaled polymyxin B be considered for a pneumonia patient?
When should use of inhaled polymyxin B be considered for a pneumonia patient?
You are reviewing the medication list for a patient with pneumonia who has a history of clinical depression and takes fluoxetine daily. What antibiotic needs special attention for potential drug interactions and adverse?
You are reviewing the medication list for a patient with pneumonia who has a history of clinical depression and takes fluoxetine daily. What antibiotic needs special attention for potential drug interactions and adverse?
In clinical practice, relying solely on past clinical experiences for prescribing antibiotics is:
In clinical practice, relying solely on past clinical experiences for prescribing antibiotics is:
What factor MUST be considered and could potentially increase the risk of superinfections while treating pneumonia?
What factor MUST be considered and could potentially increase the risk of superinfections while treating pneumonia?
A patient that is susceptible to polymyxin antibiotics should have what additional test?
A patient that is susceptible to polymyxin antibiotics should have what additional test?
For a patient with suspected HAP and a known history of structural lung disease, which is the MOST appropriate empiric treatment strategy?
For a patient with suspected HAP and a known history of structural lung disease, which is the MOST appropriate empiric treatment strategy?
Which definition BEST describes Hospital-Acquired Pneumonia (HAP):
Which definition BEST describes Hospital-Acquired Pneumonia (HAP):
Which definition BEST describes Ventilator-Associated Pneumonia (VAP):
Which definition BEST describes Ventilator-Associated Pneumonia (VAP):
For a patient with HAP or VAP whose pneumonia isolate is only susceptible to polymyxins, what adjunctive treatment is recommended?
For a patient with HAP or VAP whose pneumonia isolate is only susceptible to polymyxins, what adjunctive treatment is recommended?
What is a potential consequence of de-escalating antibiotic therapy too aggressively in the treatment of nosocomial pneumonia?
What is a potential consequence of de-escalating antibiotic therapy too aggressively in the treatment of nosocomial pneumonia?
Which organism is the least likely to cause pneumonia?
Which organism is the least likely to cause pneumonia?
What is the primary rationale for using inhaled antibiotics in conjunction with systemic antibiotics for VAP?
What is the primary rationale for using inhaled antibiotics in conjunction with systemic antibiotics for VAP?
What is the recommendation for duration of antibiotic therapy for ventilator-associated pneumonia (VAP) when using clinical criteria to guide treatment?
What is the recommendation for duration of antibiotic therapy for ventilator-associated pneumonia (VAP) when using clinical criteria to guide treatment?
Which of the following describes the clinical evidence for inhaled antibiotics?
Which of the following describes the clinical evidence for inhaled antibiotics?
If a patient is at risk of multi-drug resistance, what should the antibiotic regimen include?
If a patient is at risk of multi-drug resistance, what should the antibiotic regimen include?
Aside from structural lung disease, what is a specific risk factor for multi-drug resistant (MDR) organisms in the context of HAP?
Aside from structural lung disease, what is a specific risk factor for multi-drug resistant (MDR) organisms in the context of HAP?
Which of the following distinguishes between Colistin and Polymyxin B, and may affect clinical decision-making?
Which of the following distinguishes between Colistin and Polymyxin B, and may affect clinical decision-making?
A patient with HAP is started on vancomycin for empiric MRSA coverage. Assuming the isolate is confirmed to be MSSA, what is the next appropriate step in antibiotic stewardship?
A patient with HAP is started on vancomycin for empiric MRSA coverage. Assuming the isolate is confirmed to be MSSA, what is the next appropriate step in antibiotic stewardship?
According to the guidelines presented, what is the MOST important clinical factor in determining whether to broaden empiric antibiotic coverage for nosocomial pneumonia?
According to the guidelines presented, what is the MOST important clinical factor in determining whether to broaden empiric antibiotic coverage for nosocomial pneumonia?
What is the purpose of assessing the type of pneumonia?
What is the purpose of assessing the type of pneumonia?
Which of the following is NOT a likely causative organism specifically mentioned for HAP/VAP?
Which of the following is NOT a likely causative organism specifically mentioned for HAP/VAP?
Which is not a possible option of antibiotics that can be inhaled?
Which is not a possible option of antibiotics that can be inhaled?
In VAP, what risk factors are associated with MDR?
In VAP, what risk factors are associated with MDR?
What key information guides the selection of antibiotics?
What key information guides the selection of antibiotics?
What is considered 'off-label' in the content?
What is considered 'off-label' in the content?
A patient with known bronchiectasis is admitted with suspected HAP. Why is identifying this risk factor clinically relevant?
A patient with known bronchiectasis is admitted with suspected HAP. Why is identifying this risk factor clinically relevant?
What is the most essential component when stopping antibiotics?
What is the most essential component when stopping antibiotics?
Which of the following can play a role in possibly promoting resistance?
Which of the following can play a role in possibly promoting resistance?
An ICU patient with VAP has an endotracheal aspirate positive for Pseudomonas aeruginosa. The isolate is susceptible to meropenem, but the patient remains hypotensive despite fluid resuscitation and vasopressors. Which of the following represents the MOST appropriate definitive antibiotic strategy?
An ICU patient with VAP has an endotracheal aspirate positive for Pseudomonas aeruginosa. The isolate is susceptible to meropenem, but the patient remains hypotensive despite fluid resuscitation and vasopressors. Which of the following represents the MOST appropriate definitive antibiotic strategy?
When is use of tigecycline recommended?
When is use of tigecycline recommended?
What should always be assessed?
What should always be assessed?
What can inhaled colistin be combined with to treat Acinetobacter?
What can inhaled colistin be combined with to treat Acinetobacter?
What should be considered when choosing to use Polymyxin antibiotics?
What should be considered when choosing to use Polymyxin antibiotics?
What is the MOST accurate way to describe benefits with respect to short courses of antibiotic treatment?
What is the MOST accurate way to describe benefits with respect to short courses of antibiotic treatment?
Based on the lecture objectives, what should a provider do in selecting the best treatment?
Based on the lecture objectives, what should a provider do in selecting the best treatment?
An alert resident is requesting the use of inahled antibiotics based on the guidelines. Which of the following responses should the attending use?
An alert resident is requesting the use of inahled antibiotics based on the guidelines. Which of the following responses should the attending use?
What factors should impact the decision to provide MRSA coverage?
What factors should impact the decision to provide MRSA coverage?
Compared to longer treatment courses (10-15 days), the NICE guidelines suggest that shorter courses (7-8 days) of antibiotics for HAP/VAP may result in:
Compared to longer treatment courses (10-15 days), the NICE guidelines suggest that shorter courses (7-8 days) of antibiotics for HAP/VAP may result in:
Which is considered a newer drug to treat Pneumonia?
Which is considered a newer drug to treat Pneumonia?
What is the role of procalcitonin when discontinuing antibiotics?
What is the role of procalcitonin when discontinuing antibiotics?
What adverse effect is a rate-dependent infusion reaction?
What adverse effect is a rate-dependent infusion reaction?
What can cause increased risk for serotonin storm syndrome?
What can cause increased risk for serotonin storm syndrome?
A patient has VAP, and cultures identify carbapenem-resistant Klebsiella pneumoniae (CRKP). Susceptibility testing reveals the isolate is resistant to all antibiotics except polymyxins. What is the MOST appropriate treatment strategy?
A patient has VAP, and cultures identify carbapenem-resistant Klebsiella pneumoniae (CRKP). Susceptibility testing reveals the isolate is resistant to all antibiotics except polymyxins. What is the MOST appropriate treatment strategy?
Which of the following is a risk when it comes to antibiotic use?
Which of the following is a risk when it comes to antibiotic use?
What is the mortality range when a patient develops nosocomial pneumonia?
What is the mortality range when a patient develops nosocomial pneumonia?
In addition to mortality, what negative consequences are associated with nosocomial pneumonia?
In addition to mortality, what negative consequences are associated with nosocomial pneumonia?
Flashcards
Hospital-Acquired Pneumonia (HAP)
Hospital-Acquired Pneumonia (HAP)
Pneumonia acquired in a hospital setting, occurring ≥48 hours after admission.
Ventilator-Associated Pneumonia (VAP)
Ventilator-Associated Pneumonia (VAP)
Pneumonia occurring ≥48 hours after endotracheal intubation.
Resistant Organisms
Resistant Organisms
Infections caused by bacteria that are resistant to multiple antibiotics.
Guideline-Based Recommendations
Guideline-Based Recommendations
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Empiric or Pathogen-Directed Therapy
Empiric or Pathogen-Directed Therapy
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Treatment Plan Modifications
Treatment Plan Modifications
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Type of Pneumonia
Type of Pneumonia
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Stewardship Strategies
Stewardship Strategies
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Diagnosis of Nosocomial Pneumonia
Diagnosis of Nosocomial Pneumonia
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Selection of Antibiotics
Selection of Antibiotics
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Empiric Coverage
Empiric Coverage
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Culture-Driven Therapy
Culture-Driven Therapy
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MSSA Coverage
MSSA Coverage
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MDR Risk Factors
MDR Risk Factors
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Culture Results
Culture Results
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Vancomycin guidelines
Vancomycin guidelines
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Linezolid drug interactions
Linezolid drug interactions
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Daptomycin
Daptomycin
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Septic shock
Septic shock
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Cabapenem resistant organisms
Cabapenem resistant organisms
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Extended-spectrum Beta-lactamase
Extended-spectrum Beta-lactamase
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Antibiotic duration
Antibiotic duration
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Antibiotic therapy length
Antibiotic therapy length
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De-escalation
De-escalation
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Discontinuation
Discontinuation
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Common HAP/VAP organisms
Common HAP/VAP organisms
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Consequences of Nosocomial Pneumonia
Consequences of Nosocomial Pneumonia
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Diagnosis of HAP/VAP
Diagnosis of HAP/VAP
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Risk factors for MRSA/MDR
Risk factors for MRSA/MDR
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Antibiotics in HAP and VAP
Antibiotics in HAP and VAP
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MRSA Coverage Medications
MRSA Coverage Medications
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Antibiotic after Septic Shock resolves
Antibiotic after Septic Shock resolves
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Treat HAP/VAP
Treat HAP/VAP
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Newer anti-pneumonia drugs
Newer anti-pneumonia drugs
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Off-label investigational pneumonia agents
Off-label investigational pneumonia agents
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Older anti-pneumonia drugs
Older anti-pneumonia drugs
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Treatment for VAP
Treatment for VAP
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HAP vs. VAP: Prevalence
HAP vs. VAP: Prevalence
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Community-Acquired Pneumonia (CAP)
Community-Acquired Pneumonia (CAP)
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High Mortality Risk
High Mortality Risk
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P. aeruginosa Testing
P. aeruginosa Testing
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Procalcitonin in Pneumonia
Procalcitonin in Pneumonia
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Options for Inhaled Antibiotics
Options for Inhaled Antibiotics
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Drugs requiring Renal Dose Adjustment
Drugs requiring Renal Dose Adjustment
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HAP/VAP Pathogens: Identification
HAP/VAP Pathogens: Identification
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HAP/VAP: Resistance Risk Factors
HAP/VAP: Resistance Risk Factors
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HAP/VAP: Guideline Application
HAP/VAP: Guideline Application
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Pneumonia Classification
Pneumonia Classification
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Study Notes
- List likely organisms responsible for HAP/VAP
- List risk factors associated with resistant organisms in HAP/VAP
- Discuss key guideline-based recommendations for adults with HAP/VAP
Based on a patient's presentation:
- Assess the type of pneumonia
- Select the most appropriate empiric or pathogen-directed pharmacotherapeutic plan and stewardship strategies
- Recommend the most appropriate modifications of a patient's treatment plan based on efficacy, adverse events and follow-up assessment
Nosocomial Pneumonia: Definitions
- Community-Acquired Pneumonia (CAP): Occurs outside the health care setting; less than 48 hours from hospital admission.
- Hospital-Acquired Pneumonia (HAP): Occurs ≥48 hours after hospital admission, and the patient is not intubated at admission.
- Ventilator-Associated Pneumonia (VAP): Occurs ≥48 hours after endotracheal intubation.
Nosocomial Pneumonia: Epidemiology
- Among most common hospital-acquired infections
- HAP more common than VAP, associated with higher cost than VAP and similar mortality rate
- Associated with increased cost of care, hospital length of stay, mortality
- Mortality ranging from 15% to 50% depending on severity of illness
- Excess cost of $40,000 per patient
- Prolongs duration of hospital stay by nearly 2 weeks
- Prolongs mechanical ventilation by about 10 days
Nosocomial Pneumonia: Etiology
- Generally the same organisms that cause both infections, but in different percentages.
- HAP:
- Pseudomonas aeruginosa (19%)
- Acinetobacter spp. (13%)
- Enterobacter spp. (9%)
- Klebsiella spp. (8%)
- Serratia spp. (5%)
- Staphylococcus aureus (16–36%)
- MRSA (10%)
- VAP:
- Pseudomonas aeruginosa (20%)
- Acinetobacter baumannii (5-10%)
- Enterobacter spp. (9%)
- Klebsiella spp. (6%)
- Serratia spp. (6%)
- Staphylococcus aureus (30%)
- MRSA (n/a)
- Prevalence of pathogens varied across studies, temporally, and geographically
Nosocomial Pneumonia: Diagnosis
- Challenging because findings are usually non-specific
- Based on clinical criteria alone
- Biomarkers not recommended: lack of clinical outcomes data, sensitivity and specificity <90% of threshold set by expert panel [includes procalcitonin (PCT), soluble triggering receptor expressed on myeloid cells (sTREM-1), C-reactive protein (CRP)]
- Modified clinical pulmonary infection score (CPIS) not recommended: lack of clinical outcomes data, sensitivity and specificity <90% of threshold set by expert panel
- Chest radiography/imaging
- Blood cultures for all
- Non-invasive respiratory cultures for all
- Spontaneous expectoration, sputum induction, nasotracheal suctioning, endotracheal aspiration
Nosocomial Pneumonia: General Principles for Treatment
- Determine mortality risk (high vs low) based on:
- Need for ventilator support due to pneumonia
- Presence of septic shock (patients in shock require vasopressors)
- Selection of antibiotics should be tailored based on local antibiogram and patient's prior cultures
- Hospital-specific
- Unit-specific (Inpatient, Outpatient, ED, ICU)
- Patient-specific
- All patients should receive coverage for MSSA, P. aeruginosa, Gram-negative bacilli
- Risk factors for MRSA and/or multi-drug resistance (MDR)?
- Impacts whether to add MRSA coverage or double antipseudomonal coverage
- Risk factors for MRSA and/or multi-drug resistance (MDR)?
- Therapy should be modified based on culture results
Nosocomial Pneumonia: General Principles for Treatment - Determining risk for MRSA or MDR:
- Risk for MRSA:
- HAP:
- IV antibiotic in prior 90 d
- Hospitalization in a unit where >20% MRSA or % unknown
- VAP:
- IV antibiotic in prior 90 d
- Hospitalization in a unit where >10–20% MRSA or % unknown
- HAP:
- Risk for MDR
- HAP:
- IV antibiotic in prior 90 d
- Structural lung disease (bronchiectasis, cystic fibrosis)
- VAP:
- IV antibiotic in prior 90 d
- Septic shock at time of VAP
- ARDS preceding VAP
- ≥5 days of hospitalization prior to the occurrence of VAP
- Acute renal replacement therapy prior to VAP onset
- HAP:
Nosocomial Pneumonia: Empiric Treatment for HAP
- Low risk for mortality and low risk for MRSA:
- Piperacillin-tazobactam, cefepime, imipenem, meropenemLevofloxacin
- Low risk for mortality, high risk for MRSA
- Piperacillin-tazobactam, cefepime, imipenem, meropenem, aztreonam + Vancomycin, linezolid
- High risk for mortality or high risk for MDR:
- Piperacillin-tazobactam, cefepime, imipenem, meropenem, aztreonam + Levofloxacin, ciprofloxacin + Amikacin, gentamicin, tobramycin + Vancomycin, linezolid
Nosocomial Pneumonia: Empiric Treatment for VAP
- No risk for MDR, GN-r <10%, and MRSA <10%:
- Piperacillin-tazobactam, cefepime, imipenem, meropenem + Levofloxacin
- No risk for MDR, GN-r <10%, MRSA >10% or unknown
- Piperacillin-tazobactam, cefepime, imipenem, meropenem, aztreonam + Levofloxacin, ciprofloxacin + Vancomycin, linezolid
- No risk for MDR, GN-r >10%, MRSA >10% or unknown
- Piperacillin-tazobactam, cefepime, imipenem, meropenem, aztreonam + Levofloxacin, ciprofloxacin + Amikacin, gentamicin, tobramycin + Colistin, polymyxin B + Vancomycin, linezolid
- Risk for MDR
- Piperacillin-tazobactam, cefepime, imipenem, meropenem, aztreonam + Levofloxacin, ciprofloxacin + Amikacin, gentamicin, tobramycin + Colistin, polymyxin B + Vancomycin, linezolid
Nosocomial Pneumonia: Pathogen-Specific, Definitive Therapy - Methicillin-resistant Staphylococcus aureus (MRSA)
- Vancomycin:
- Guidelines suggest maintaining AUC/MIC ≥ 400 for complicated S.aureus infections including pneumonia.
- AUC ≥ 400 mg*hr/L for isolates with MIC of 1 mg/L
- Target trough concentration 15-20 mg/L as surrogate for AUC ≥ 400mg*hr/L (traditionally)
- Loading dose 25-30 mg/kg (actual body weight) in seriously ill
- Maintenance doses 15-20 mg/kg (actual body weight) every 8 to 12hours
- Draw trough concentration at steady-state (5 x t1/2, usually before 4th dose)
- Adverse effects:
- Nephrotoxicity
- Ototoxicity
- Red-Man Syndrome
- Rate-dependent infusion reaction (not true allergy)
- Vancomycin direct activation of mast cells to release histamine
- Flushing, erythema, pruritus (upper body, neck, face > lower body)
- Stop infusion, administer antihistamine, restart infusion at slower rate
- Guidelines suggest maintaining AUC/MIC ≥ 400 for complicated S.aureus infections including pneumonia.
- Linezolid
- 600 mg IV q12h
- Drug-drug interactions:
- SSRIs (fluoxetine, e.g.), tricyclic antidepressants, trazodone, venlafaxine, mirtazapine: Increased risk for serotonin storm syndrome
- Adverse effects:
- Myelosuppression
- Serotonin syndrome
- Traditionally more expensive than vancomycin
- Other agents
- Daptomycin: NEVER use for pneumonia because it is inactivated by surfactant
- Limited evidence with teicoplanin, telavancin, ceftaroline, tedizolid
Nosocomial Pneumonia: Pathogen-Specific, Definitive Therapy
- Pseudomonas aeruginosa
- Based on antibiotic susceptibility testing: Routine antimicrobial susceptibility testing should include assessment of the sensitivity of the P. aeruginosa isolate to polymyxins (colistin or polymyxin B) in settings that have a high prevalence of extensively resistant organisms
- Septic shock resolves or not at high risk for mortality, and susceptibility known
- Monotherapy with an agent to which the patient isolate is susceptible
- Monotherapy with aminoglycosides is NOT RECOMMENDED
- In septic shock or at high risk for death, even if susceptibility known
- Combination therapy (2 agents)
- If septic shock resolves, deescalate to monotherapy
- Acinetobacter spp.
- Based on antibiotic susceptibility testing
- Carbapenem or ampicillin/sulbactam if patient isolate susceptible to either
- If only susceptible to polymyxins, IV polymyxin + adjunctive inhaled colistin
- If only susceptible to colistin, use of rifampicin not recommended
- Use of tigecycline not recommended
- Based on antibiotic susceptibility testing
- Carbapenem-resistant organisms
- Based on antibiotic susceptibility testing
- If only susceptible to polymyxins, IV polymyxin + adjunctive inhaled colistin
- Inhaled polymyxin B not recommended due to lack of supporting clinical evidence
- Based on antibiotic susceptibility testing
- Extended-spectrum Beta-lactamase (ESBL)—producing Gram-negative bacilli
- Based on antibiotic susceptibility testing
- Consider allergies and comorbid conditions that increase the risk for side effects
- Based on antibiotic susceptibility testing
Nosocomial Pneumonia: Other Treatment Strategies
- Newer drugs
- Ceftazidime/avibactam
- Ceftolozane/tazobactam
- Off-label investigational agents
- Meropenem/vaborbactam
- Imipenem/Cilastatin/Relebactam
- Older drugs
- Colistin (colistimethate sodium)
- Polymyxin B
- Inhaled antibiotics
Nosocomial Pneumonia: Other Treatment Strategies
| Ceftazidime/Avibactam | Ceftolozane/Tazobactam | |
|---|---|---|
| FDA Indication | Yes | Yes |
| Activity most ESBL | Yes | Yes |
| Activity against AmpC Beta-lactamase | Yes | Yes |
| Activity cabapenems | No | No |
| Efficacy data | vs Meropenem efficacy the same | vs Meropenem efficacy the same |
| Meropenem/Vaborbactam | Imipenem/Cilastatin/Relebactam | |
|---|---|---|
| FDA Indication | No | No |
| Activity most ESBL | Yes | Yes |
| Activity against AmpC Beta-lactamase | Yes | Yes |
| Activity cabapenems | Yes | No |
| Efficacy data | vs best available therapy = similar efficacy | Overall response HAP/VAP: I/C/R vs meropenem - efficacy the same; Clinical cure at test of cure: same |
| Colistin (Polymyxin E) | Polymyxin B | |
|---|---|---|
| FDA Indication | No | No |
| Activity most ESBL | Yes | Yes |
| Activity against AmpC Beta-lactamase | Yes | Yes |
| Activity cabapenems | Yes | Yes |
| Administration routes | IV, inhaled (off label) | IV, inhaled (off label) |
| Elimination | Primarily renal | Primarily non-renal |
| Renal adjustment | Yes | No |
| Formulation | Inactive prodrug activated | Active metabolite |
| Nephrotoxicity | No increase | Increase |
| Neurotoxicity | increase | increase |
Nosocomial Pneumonia: Other Treatment Strategies - Inhaled Antibiotics
- Recommendations
- Use combination inhaled and systemic antibiotics for VAP due to MDR gram-negative bacilli susceptible only to aminoglycosides or polymyxins
- For HAP/VAP with Acinetobacter spp., if only susceptible to polymyxins, IV polymyxin + adjunctive inhaled colistin
- For HAP/VAP with carbapenem-resistant organisms, if only susceptible to polymyxins, IV polymyxin + adjunctive inhaled colistin
- Inhaled options: Colistin, gentamicin, tobramycin (inhaled polymyxin B lacks clinical evidence)
- Advantage: Increased clinical cure rate (potential?)
- Disadvantage: Increased burden and cost
- Clinical evidence: No proven effects on mortality, adverse reaction, or antibiotic resistance
- Unknown: Optimum dosing, delivery method, patient population with greatest benefit
Nosocomial Pneumonia: Duration of Therapy - For both HAP and VAP
- Recommendations: 7 days
- Benefits of short courses (7-8 days) vs long courses (10-15 days) of antibiotic therapy:
- Increased antibiotic-free days
- Reduced rates of recurrent VAP due to MDR organisms
- No difference between short courses (7-8 days) vs long courses (10-15 days) of antibiotic therapy with respect to:
- Mortality
- Recurrence of pneumonia
- Ventilator-free days
- Duration of mechanical ventilation
- ICU length of stay
Nosocomial Pneumonia: Antibiotic Stewardship
- De-escalation recommended
- Switch from empiric broad-spectrum therapy to therapy with narrower spectrum of activity
- Clinical evidence comparing de-escalation to fixed, broad-spectrum therapy
- No significant difference in mortality or ICU length of stay
- Conflicting evidence regarding impact on pneumonia recurrence
- De-escalation may increase antimicrobial days, superinfection rates, and MRSA emergence
- Recommendation based on expert clinical experience and clinical rationale
- De-escalation should reduce cost, burden, and antimicrobial resistance
- It is doubtful that de-escalation could increase antibiotic days and superinfection
- Procalcitonin concentration + clinical criteria to guide discontinuation
- Precursor of calcitonin, rises in response to bacterial infections
- Best-established to guide early discontinuation of antibiotics in VAP
- Evidence is predominantly from VAP, extrapolated to HAP
- Evidence supporting use of procalcitonin concentrations
- Shorter duration of antibiotic therapy (i.e. lower exposure)
- No significant differences in mortality, pneumonia recurrence, mechanical ventilation, ICU/hospital length of stay, development of resistance
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