how to manage HAP in ICU?

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TREATMENT

The treatment of must be early, prompt and, by necessity, empiric. Once again, get cultures before starting antibiotics. Empiric therapy depends in part on the setting, epidemiological patterns in the hospital, and severity of illness. For patients who are seriously ill without microbiologic diagnosis, intravenous antibiotic therapy can be based on published recommendations from the American Thoracic Society (Table 1).

Table 1. Hospital-acquired Pneumonia - ATS Recommendations 1995
Aminoglycoside e. g. gentamicin or tobramycin or intravenous fluoroquinolone plus

b-lactam antibiotic with antipseudomonal activity, e. g. piperacillin, ceftazidime if indicated, or imipenem

With or without vancomycin

The typical regimen at UCDMC is cefipime alone or piperacillin + gentamicin but if you suspect P. aeruginosa, select piperacillin (or ceftazidime) + gentamicin or ciprofloxacin. Add metronidazole (or clindamycin) if you suspect anaerobes (Table 2).

Table 2. Hospital-acquired Pneumonia - UCDMC Recommendations 2000
Pseudomonas aeruginosa not suspected

cefipime or piperacillin + gentamicin

Pseudomonas aeruginosa suspected

Piperacillin or ceftazidime + gentamicin or ciprofloxacin

Add metronidazole or clindamycin if you suspect anaerobes

Alternative regimens

Intravenous levofloxacin + gentamicin for complicated community pneumona
and nosocomial pneumonia

Imipenem + tobramycin

Add fluoroquinolone or macrolide if Legionella infection suspected

Add fluconazole or amphotericin B if fungal infection suspected
Jeffrey H. King, Pharm. D.
Associate Professor
UCSF School of Pharmacy

You should always treat P. aeruginosa with two antibiotics. Vancomycin has been restricted because of the epidemic of vancomycin-resistant enterococci (VRE) in hospitalized patients linked to overuse of second- and third-generation cephalosporins. The intravenous fluoroquinolone trovofloxacin has broad spectrum activity against P. aeruginosa, S. aureus, E. coli, and anaerobes and may be used to treat nosocomial pneumonia empirically in combination with an aminoglycoside or aztreonam. Once you identify the pathogen causing HAP, narrow your antibiotic regimen to avoid antibiotic toxicity and the threat of fungal pneumonia with Candida spp. or Aspergillus spp.

The optimal duration of antibiotic therapy has not been evaluated by prospective clinical trials. Duration of therapy should be individualized, depending on the severity of illness, rapidity of clinical response, and infecting pathogen. A 14- to 21-day course of antibiotics is recommended for P. aeruginosa or Acinetobacter spp., presence of multilobar involvement, malnutrition, severe debilitation, or evidence of necrotizing pneumonia. A 7- to 10-day course of antibiotic therapy may be adequate for S. aureuspneumonia. Substituting an oral antibiotic after clinical improvement has occurred requires further study to determine efficacy. There is an potential opportunity to reduce hospital costs. In this context, the oral fluoroquinolones may be acceptable choices with their broad spectrum of coverage and high levels in bronchopulmonary secretions.

Given the attributable mortality of HAP is between 20% to 40% (or 33% to 50% according to the American Thoracic Society), it is clear that many patients are not expected to survive even with appropriate antibiotic therapy. HAP caused by P. aeruginosa or Acinetobacter spp. in mechanically ventilated patients is associated with a mortality rate approaching 90% in published clinical studies.

When a patient fails to improve or deteriorates despite empiric antibiotic treatment, you must consider a differential diagnosis including atelectasis, congestive heart failure, pulmonary embolism with infarction, lung contusion especially in trauma patients, pulmonary hemorrhage, adult respiratory distress syndrome (ARDS), Pneumocystis carinii pneumonia, tuberculosis, and chemical pneumonitis from aspiration.

Poor prognostic signs include prolonged mechanical ventilation for respiratory failure, age > 60 years, bilateral radiographic infiltrates, prior antibiotic treatment, prior pneumonia, and/or chronic lung disease.

Get cultures before starting antibiotics. Do, or do not, There is no try.

At UCDMC, choose ceftizoxime + gentamicin for empiric treatment of HAP but if you suspect P. aeruginosa, choose piperacillin (or ceftazidime) + tobramycin ± metronidazole (or clindamycin) if you suspect anaerobes.

Treat patients for 14- to 21 days but remember to individualize treatment based on the severity of illness and co-morbid factors

Poor prognostic signs are prolonged mechanical ventilation for respiratory failure, age > 60 years, bilateral radiographic infiltrates, prior antibiotic treatment, prior pneumonia, and/or chronic lung disease.

Other Answers:
There are now joint commision guideline for treating and proventing hap. There is also things to do as a respiratory therapist (me) to prevent them. We used a vent bundle at a hospital that i used to work at and had almost no cases so hap. go to the joint commisions web site

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how to manage HAP in ICU?

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