(2/26) Glowacki Lecture: Hospital Acquired Pneumonia (HAP ...€¦ · (2/26) Glowacki Lecture:...
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(2/26) Glowacki Lecture: Hospital Acquired Pneumonia (HAP)/Ventilator-Associated Pneumonia (VAP) Mechanisms of Infection: Microorganisms can gain access to the lungs via aerosolized particles, hematogenously (via blood), or through aspiration. There is an increased pathogenesis when the lung defenses are impaired. - Impaired Lungs: Neuromuscular disorders (Guillian Barre, MS, Seizures), CF, CVD disorders - Physical Impairment: Altered sensorium (booze), Viral infection affecting macrophages, colonization Hospital-Acquired Pneumonia (HAP): Acute infection of the pulmonary parenchyma in patients at least 48 hours after being hospitalized, but not intubated, at the time of admission. This includes nursing home patients. - Ventilator-Associated Pneumonia (VAP): Pneumonia that develops after 48 hours of a patient being intubated - As high as 25-58% of patients on ventilators will develop HAP. There is a 12-29% incidence of HAP in ICU patients. The inanimate environment at the hospital can facilitate transmission, as contaminated surfaces can increase cross-transmission - Etiology: The geographic area of the facility may vary o Gram Negative: 60%. – Pseudomonas aeruginosa o Gram Positive: 18%. – Staph aureus o Other (fungi, viral, atypicals) 22% - Risk Factors: Intubation is a straight shot through the gullet. Length of hospitalization, H2RA use, PPI use, Age > 70, aspiration, prior abx exposure, malnutrition, drugs, sinusitis, bacteremia o MDR Risk Factors: Abx in last 90 days, >5days hospitalized, Septic Shock at time of VAP, Acute respiratory distress syndrome (ARDS) preceding VAP, and acute renal replacement therapy prior to VAP - S/Sx: CXR Infiltrates, Increased secretions, Increased O2 needs, Chest discomfort, Cough, Tachypnea, Lung sounds, Tachycardia, Chills/Rigors - Diagnosis: CXR, Cultures (sputum, endotracheal tube), New s/sx: Fever, ÝWBC, Increased sputum production Treatment of HAP – Empiric broad-spectrum abx are chosen with some basis on local susceptibility patterns - Factors involved in selecting a drug regimen: The antibiotic characteristics o Pharmacokinetics: Dosing Method, Concentration used o Pharmacodynamics: Action should be Bactericidal - Cover for MRSA if: MDR risk factor, patient’s environment has >10-20k% incidence of MRSA, Prevalence of MRSA is not known and/or patient is intubated/septic shock o à Vancomycin (dosed at troughs of 15-20mcg/mL OR Linezolid 600mg IVPB q12º § Daptomycin cannot be used for HAP because it does not enter the lungs - No MRSA Risk factors o à Pip/Tazo OR Cefepime OR Levofloxacin OR Imipenem OR Meropenem - MSSA Isolated o à Nafcillin OR Oxacillin OR Cefazolin - Cover with 2 drugs for Pseudomonas or resistant G(-) if: MDR risk factor, ³ 10% incidence or resistance, prevalence not known or intubated and patient has structural lung disease (CF, Bronchiectasis) o Antipseudomonal Cephalosporin: Cetazadime OR Cefipime o Antipseudomonal Carbapenem: Imipenem OR Meropenem o b-lactam/b-lactamase Inhibitor: PipTazo o ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ o Antipseudomonal Fluoroquinolone: Levofloxacin OR Ciprofloxacin o Aminoglycoside: Gentamicin OR Tobramycin OR Amikacin o Polymixin: Colistin OR Polymixin B - These are saved for isolation of fairly resistant organisms - Special Treatment Considerations o Risk for Anaerobes à Metronidazole or Clindamycin to be added. (Except for Imipenem, Meropenem, PipTazo) o Fungus Isolated or suspected à Amphoterrible. Switch to Voriconazole if Aspergillosis identified o Extended-Spectrum b-lactamase Organismà Carbapanem + b-lactamase inhibitor, Fluoroquinolone ±AG o KPC: Carbapenem Resistance à Colistin and Polymixin B - PK/PD/DDI Considerations o Renal Adjustment: Levo, Cipro, Aztreo, Carbapenems, Cephalosporins, PipTazo, AG, Vanco, Polymixins o DDI: Fluoroquinolones- avoid antacids, iron, magnesium, aluminum, calcium § Linezolid: Avoid SSRI, TCA, Trazodone, Venlafaxine, Mirtazipine (Serotonin Syndrome) o Adverse Effects § Fluoroquinolones: Tendon rupture, QTc prolongation, Hypoglycemia One of these….. And one of these
Transcript of (2/26) Glowacki Lecture: Hospital Acquired Pneumonia (HAP ...€¦ · (2/26) Glowacki Lecture:...
(2/26) Glowacki Lecture: Hospital Acquired Pneumonia (HAP)/Ventilator-Associated Pneumonia (VAP) Mechanisms of Infection: Microorganisms can gain access to the lungs via aerosolized particles, hematogenously (via blood), or through aspiration. There is an increased pathogenesis when the lung defenses are impaired.
- Impaired Lungs: Neuromuscular disorders (Guillian Barre, MS, Seizures), CF, CVD disorders - Physical Impairment: Altered sensorium (booze), Viral infection affecting macrophages, colonization
Hospital-Acquired Pneumonia (HAP): Acute infection of the pulmonary parenchyma in patients at least 48 hours after being hospitalized, but not intubated, at the time of admission. This includes nursing home patients.
- Ventilator-Associated Pneumonia (VAP): Pneumonia that develops after 48 hours of a patient being intubated - As high as 25-58% of patients on ventilators will develop HAP. There is a 12-29%
incidence of HAP in ICU patients. The inanimate environment at the hospital can facilitate transmission, as contaminated surfaces can increase cross-transmission
- Etiology: The geographic area of the facility may vary o Gram Negative: 60%. – Pseudomonas aeruginosa o Gram Positive: 18%. – Staph aureus o Other (fungi, viral, atypicals) 22%
- Risk Factors: Intubation is a straight shot through the gullet. Length of hospitalization, H2RA use, PPI use, Age > 70, aspiration, prior abx exposure, malnutrition, drugs, sinusitis, bacteremia
o MDR Risk Factors: Abx in last 90 days, >5days hospitalized, Septic Shock at time of VAP, Acute respiratory distress syndrome (ARDS) preceding VAP, and acute renal replacement therapy prior to VAP
- S/Sx: CXR Infiltrates, Increased secretions, Increased O2 needs, Chest discomfort, Cough, Tachypnea, Lung sounds, Tachycardia, Chills/Rigors
- Diagnosis: CXR, Cultures (sputum, endotracheal tube), New s/sx: Fever, ÝWBC, Increased sputum production Treatment of HAP – Empiric broad-spectrum abx are chosen with some basis on local susceptibility patterns
- Factors involved in selecting a drug regimen: The antibiotic characteristics o Pharmacokinetics: Dosing Method, Concentration used o Pharmacodynamics: Action should be Bactericidal
- Cover for MRSA if: MDR risk factor, patient’s environment has >10-20k% incidence of MRSA, Prevalence of MRSA is not known and/or patient is intubated/septic shock
o à Vancomycin (dosed at troughs of 15-20mcg/mL OR Linezolid 600mg IVPB q12º § Daptomycin cannot be used for HAP because it does not enter the lungs
- No MRSA Risk factors o à Pip/Tazo OR Cefepime OR Levofloxacin OR Imipenem OR Meropenem
- MSSA Isolated o à Nafcillin OR Oxacillin OR Cefazolin
- Cover with 2 drugs for Pseudomonas or resistant G(-) if: MDR risk factor, ³ 10% incidence or resistance, prevalence not known or intubated and patient has structural lung disease (CF, Bronchiectasis)
o Antipseudomonal Cephalosporin: Cetazadime OR Cefipime o Antipseudomonal Carbapenem: Imipenem OR Meropenem o b-lactam/b-lactamase Inhibitor: PipTazo o ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ o Antipseudomonal Fluoroquinolone: Levofloxacin OR Ciprofloxacin o Aminoglycoside: Gentamicin OR Tobramycin OR Amikacin o Polymixin: Colistin OR Polymixin B - These are saved for isolation of fairly resistant organisms
- Special Treatment Considerations o Risk for Anaerobes à Metronidazole or Clindamycin to be added. (Except for Imipenem, Meropenem,
PipTazo) o Fungus Isolated or suspected à Amphoterrible. Switch to Voriconazole if Aspergillosis identified o Extended-Spectrum b-lactamase Organismà Carbapanem + b-lactamase inhibitor, Fluoroquinolone ±AG o KPC: Carbapenem Resistance à Colistin and Polymixin B
- PK/PD/DDI Considerations o Renal Adjustment: Levo, Cipro, Aztreo, Carbapenems, Cephalosporins, PipTazo, AG, Vanco, Polymixins o DDI: Fluoroquinolones- avoid antacids, iron, magnesium, aluminum, calcium
§ Linezolid: Avoid SSRI, TCA, Trazodone, Venlafaxine, Mirtazipine (Serotonin Syndrome) o Adverse Effects
§ Fluoroquinolones: Tendon rupture, QTc prolongation, Hypoglycemia
One of these…..
And one of these
§ Linezolid: Myelosuppresion, 5HT syndrome § Nafcillin/Oxacillin: Rash § Carbapenems: Rash, D, Seizures § PipTazo: Thrombocytopenia § Aminoglycosides: Nephrotoxicity, Ototoxicity
- Preventions o Hand hygiene, gloves and gown, proper cleaning of equipment, isolation
(2/28) Gross Lecture: Pharmacotherapy of Antifungal Agents I There are 1.5 million species of fungi, but <50 of them cause 90% of the fungal infections in humans and animals
- However, incidence is increasing, and some say it is because global warming is making the environmental temperatures more similar to our formerly distant warm-blooded state. (-.-)?
Meet the Fungi! - Classification based on structure
o Unicellular (Yeasts): Single spherical cells with rigid cell walls o Filamentous (Molds): Fuzzy, like tiny trees, with filaments called hyphae, collectively mycelium o Dimorphism: Existing as either yeasts (>37ºF) or molds (depending on the environment)
- Opportunistic Fungi o Candida albicans: A yeast very commonly associated with infections. They
reproduce by budding. o Cryptococcus neoformans: Another main yeast, Huge capsule o Aspergillus umigatus: A mold frequently affecting humans. It has hyphae, as
well as a conidia-phore giving rise to conidia spores for reproduction - Dimorphic Fungi
o Blastomyces dermatitidis o Coccidiodes immitis o Histoplasma capsulatum
- The idea here is, if you determine there is yeast here or there,
growth it on a medium and check it on a microscope Compared to bacteria…
- Resistance: Fungi develop less resistance, and do so at a very slow rate. They have been shown to be stable o Generally, species predicts susceptibility**
- Affected Patients: Usually only found in immunocompromised individuals or exposure through healthcare - Incidence of Infection: It is increasing… hmm global warming????? \(-.-)/ \(=.=)/
Types of fungal infections - Superficial Fungal Infections: Referring to the skin most commonly. Such as thrush, tinia, dermatophytoses
o Treat Topically - Systemic Fungal Infections: Infections that have invaded the internal organs, such as opportunistic pathogens and
a debilitated host. Systemic mycoses are increasing due to increasing population of immunocompromised patients Candida spp: General Susceptibilities
- C. albicans: Most commonly found and most susceptible - C. parapsilosis: Elevated MIC to echinocandins - C. glabrata: Historically has shown strong resistance,
requiring higher doses. If isolated à Echinocandin - C. krusei: Always resistant to fluconazole. Yet like
glabrata are routinely susceptible to Echinocandins
Resistant Candida? à Echinocandin! Amphotericin B “Amphoterrible”
- MoA: Amphotericin binds ergosterol in fungal cell membranes to form aggregates, leading to the formation of pores that leak cellular contents and cause cell death, killing the fungi
- Formulations: Deoxycholate (original), Liposomal (Ambisome), and Lipid complex (Abelcet) - Spectrum: Broadest spectrum antifungal, covering nearly all yeasts and molds with fungicidal activity
o Covers: Candida (but not lusitaniae), Aspergillus (but not terreus), Cryptococcus, Mucor, endemic fungi
Echinocandin
