HAP/VAP

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Hospital-Acquired and Ventilator-Acquired Pneumonia (HAP/VAP)

Indications

  • HAP: PNA occurring 48 or more hours after admission
  • VAP: PNA occurring 48 or more hours after ET intubation
    • Click here for VAP diagnosis algorithm (SUSAN - link to PDF)
  • Risk factors for multi-drug resistant pathogens
    • Prior IV antibiotic use within 90 days
    • Septic shock at time of VAP
    • ARDS preceding VAP
    • Five or more days of hospitalization prior to VAP occurrence
    • Acute renal replacement therapy prior to VAP onset

First line treatment

  • Cefepime 2g IV every 8 hours plus Vancomycin 15mg/kg IV every 12 hours*
  • With MDRP risk factors, add Tobramycin 5-7mg/kg IV daily**
  • De-escalate once sensitivities are available.

Penicillin alternatives

  • Aztreonam 2g IV every 8 hours plus Vancomycin 15mg/kg IV every 12 hours*
  • With MDRP risk factors, add Tobramycin 5-7mg/kg IV daily**
  • De-escalate once sensitivities are available.

Duration

  • 7 days

Notes

Consider empiric choices above do not cover:

  • Stenotrophomonas spp: When sensitive, use Bactrim 15-20 mg/kg IV every 8 hours.
    • Avoid levofloxacin as single agent.
    • Consider requesting sensitivities to ceftazidime as some patients will not tolerate Bactrim.
  • Acinetobacter spp: When sensitive, use Unasyn 3g IV every 6 hours.

IDSA guidelines do not support longer courses of antibiotics, even for (previously recommended) non-glucose-fermenting gram-negative bacilli. There is some support for a 5-day course of antibiotics in the setting of rapid recovery/defervescence. 

*For any toxic patient, consider a Vancomycin loading dose of 25 mg/kg followed by 15 mg/kg every 12 hours. Every Vancomycin order requires pharmacokinetic consult.

**For patients who remain in septic shock/high risk of death, consider continuing two anti-pseudomonas agents for entire treatment course, regardless of sensitivities.

 

Disclaimer: The contents of this application are for the exclusive and specific use of University of Mississippi Medical Center faculty and trainees. Any other use is neither authorized nor sanctioned by UMMC. The information is for educational purposes only. The contents of this application are for the exclusive and specific use of UMMC faculty and trainees. Any other use is neither authorized nor sanctioned by UMMC. The information is for educational purposes only.