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Iowa Lutheran Family Medicine Residency Program

PIAC Case Series

ANSWERS
Case 06 - Terry, 35 years old

Terry is a 35 y/o hospitalized with severe trauma due to MVA. He is diagnosed with VAP (ventilator-associated pneumonia) on hospital day 5.

Questions

1) What are the likely organisms?

Answers

Likely organisms depend in part on length of stay prior to onset

  • Early onset consider - strep pneumo, hemophilus, MSSA

    Late onset
  1. Pseudomonas
  2. Staph aureus (MSSA or MRSA)
  3. Enterobacter/Klebsiella


Questions

2) What are the measures in ventilator bundle for prevention of VAP?

Answers

Components in bundle to prevent VAP are

- Head of bed elevation
- Oral cares with chlorhexidine
- Daily sedation vacation/assessment of readiness to extubate
- Closed suction system, ETT with subglottic suctioning


Questions

3)  What are some principles of antimicrobial therapy for VAP?

Answers

Principles of antimicrobial therapy for VAP include:

1. identify the pathogen

  • Bronch brush specimens or tracheal aspirates for gm stain and culture, while not perfect often do identify the pathogen
  • Remember, sputum is NOT a sterile body fluid and oro-pharyngeal colonizing flora may be present. For example, candida in these cultures is causing mucosal colonization, not pneumonia.

2. use maximal dose antibiotic with good lung penetration/activity
For example - aminoglycosides have poor lung penetration and daptomycin is INACTIVE in the lung   

3. general length of therapy = 7 - 8 days . Some host settings will require longer therapy - ie, underlying bullous lung disease, empyema.

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