HCAP treatment guidelines (clinical question)

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rcodyfb16

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I'm currently rotating through a facility that has guidelines to treat HCAP with concurrent Zosyn levaquin and vanc. As this is my first rotation, I'm not too sure how common/uncommon this abx course is. From what I can tell the vanc is there only for MRSA coverage? I'm doing my project on antibiotic resistances. We had a patient who received all 3 abx but wasn't tested for MRSA prior to initiating treatment. What am I missing here? Thanks for any insight!

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Recommend reviewing new HAP guidelines. No such thing as HCAP anymore.
 
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You should review your ID notes from school so you can understand why each agent is being used. If you don't know the most common bugs, you won't know why we use these drugs.

Echo reading the 2016 IDSA update on HAP/VAP that bacillus suggested. Especially focus on what patients are at risk for MDRO and warrant aggressive empiric therapy.

Afterwards we can get into whether VZL is an appropriate empiric treatment...
 
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You should review your ID notes from school so you can understand why each agent is being used. If you don't know the most common bugs, you won't know why we use these drugs.

Echo reading the 2016 IDSA update on HAP/VAP that bacillus suggested. Especially focus on what patients are at risk for MDRO and warrant aggressive empiric therapy.

Afterwards we can get into whether VZL is an appropriate empiric treatment...
Yes from my understanding the levaquin will treat g+ excluding MRSA and g- excluding pseudomonas. Pip/taz has a little g+ coverage but will cover the pseudomonas. The only thing it looks like the vanc is used for is MRSA, so my question was if MRSA could be ruled out could it be taken off?
I didn't realize how long a culture would take to come back which is why I assume its part of empiric therapy. Thanks for the reply!
 
Yes from my understanding the levaquin will treat g+ excluding MRSA and g- excluding pseudomonas. Pip/taz has a little g+ coverage but will cover the pseudomonas. The only thing it looks like the vanc is used for is MRSA, so my question was if MRSA could be ruled out could it be taken off?
I didn't realize how long a culture would take to come back which is why I assume its part of empiric therapy. Thanks for the reply!

Many incorrect statements - please review your drugs and spectrum of activity. I highly recommend purchasing a copy of the Sanford Guide.

Of course if any organism is ruled out, it is an opportunity to de-escalate- the real questions are what % of pneumonia patients have an identifiable respiratory pathogen on culture, and for those who don't what other data can help us tailor antimicrobial therapy?
 
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This course looks to be for empiric therapy that covers nearly everything. Vanco covers nearly all g+ including MRSA, Levofloxacin is for the atypical coverage, and Pip/Tazo is for g- including Pseudomonas. I'd imagine that C&S testing would occur thus de-escalate therapy from there.
 
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I'm a little surprised by the backlash to this question. The 2016 IDSA guidelines don't recommend use of vancomycin or linezolid for HAP unless:
1. Patient has risk factors for MRSA infection OR
2. Patient is at high risk for mortality

I think the question asker is right to question the therapy choice. The 2016 guidelines view vancomycin as primarily adding coverage for MRSA. The therapy may still be appropriate (e.g. hospital has high rates of MRSA infections, the patient received recent IV antibiotics, the patient isn't doing very well...), but it's appropriate to try to identify the reason.

People here are mean :/
 
*levofloxacin has PA coverage too although not as strong as ciprofloxacin (no pulmonary activity though for ciprofloxacin)

It's a common misconception that ciprofloxacin has no "pulmonary activity" (a la daptomycin). The idea that cipro is not a respiratory FQ refers to the fact that it does not cover the most common, gram positive, causes of pneumonia (ex. strep pneumo), not that it doesn't have adequate availability within pulmonary tissue.
 
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I'm still not on board with double coverage using FQ's - why add on an agent that has more gram (-) resistance than Zosyn/Cefepime thinking it's more likely to cover that MDRO?
 
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I'm still not on board with double coverage using FQ's - why add on an agent that has more gram (-) resistance than Zosyn/Cefepime thinking it's more likely to cover that MDRO?
It provides atypical coverage though
 
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