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A 63-year-old female is in the intensive care unit for urosepsis. She required intubation and mechanical ventilation early in the course. Blood and urine cultures initially grew Escherichia coli and sterilized within 2 days of admission. However, she was unable to be extubated because of depressed mental status. The patient is started on enteral nutrition through a nasogastric tube. On the seventh hospital day the patient has increasing respiratory secretions and a fever. A chest radiogram is obtained and shows a new infiltrate in the right lower lobe. Current medications include cefazolin, omeprazole, and acetaminophen.
Appropriate antibiotic therapy for this patient would be
A. ceftazidime
B. ceftriaxone and azithromycin
C. levofloxacin
D. vancomycin and ceftazidime
E. vancomycin
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Harrison Q
The answer is D.
Hospital-acquired pneumonia (HAP) remains a common problem, affecting 5 to 10% of all medical and surgical discharges, with an associated mortality of 30 to 70%. The most common microbe is Staphylococcus aureus, including methicillin-resistant strains; however, enteric gram-negatives also are important pathogens. Risk factors include impaired host defenses, including nasogastric and endotracheal intubation and enteral feedings, which increase the risk of microaspiration and macroaspiration. In critically ill patients, elevated gastric pH resulting from antacids, proton pumps, and H2 inhibitors and enteral feedings are associated with gastric bacterial overgrowth. This bacterial burden can in turn be aspirated. Current recommendations suggest weighing the benefits of gastrointestinal prophylaxis against the risk of bacterial overgrowth and potential aspiration and/or pneumonia. To minimize HAP risk, placement of enteral feeding tubes ideally should be postpyloric and the tube should be the smallest caliber possible. Ventilator circuit manipulations are associated with an increased risk of HAP, and thus circuit changes should be minimized. Neither prophylactic antibiotics nor selective gastrointestinal decontamination has been shown to decrease the risk of HAP. Importantly, elevation of the head of the bed to 30° has been shown in randomized trials to decrease the risk of HAP. Initial therapy is empirical and should cover the most likely pathogens: S. aureus and enteric gram-negative bacilli. In light of the frequency of methicillin-resistant S. aureus, it would be most appropriate to use vancomycin and a third-generation cephalosporin or penicillin with antipseudomonal activity.
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Im sorry lucidinterval ......ans the next one
