A 63-year-old male, post head trauma, is intubated and has been ...

[pepyto]

A 63-year-old male, post head trauma, is intubated and has been mechanically ventilated for 78 hours.
 
  The respiratory therapist notes the following during ICU rounds: partial pressure of oxygen in the arteries (PaO2) is 82 mm Hg on 60 supplemental oxygen with a positive end-expiratory pressure (PEEP) of 8 cm H2O; static compliance is averaging 38-41 cm H2O/L; breath sounds are dimin-ished bilaterally. Bronchoalveolar lavage (BAL) results are pending, but MRSA is suspected. Chest radiograph shows bilateral, patchy infiltrates. Patient has a temperature of 38.8 C, and the most recent white blood cell (WBC) count is 11,300 L. The most appropriate recommendation for this patient is which of the following?
  a. Monotherapy with an antipseudomonal carbepenem
  b. Monotherapy with an antipseudomonal fluoroquinolone
  c. Combination therapy with two types of antipseudomonal agents and vancomycin
  d. Combination therapy with ampicil-lin/sulbactam and linezolid

Question 2

Reasons for the shift in oropharyngeal flora in patients receiving invasive mechanical ventilation with endotracheal tubes include which of the following?
 
  a. Lowered pH levels
  b. Increase in mucus-producing cells
  c. Decreased production of proteases
  d. Decreased mucosal immunoglobulin A

[joewallace]

Answer to Question 1

ANS: C
This patient has late-onset ventilator-associated pneumonia because he has been intubated and has received mechanical ventilation for longer than 72 hours. Because MRSA is suspected, com-bination antibiotic therapy should be used. According to Table 14-2 this would include two an-tipseudomonal agents plus either vancomycin or linezolid. Therapy should be adjusted once the microbiological data confirm the organism.

Answer to Question 2

ANS: D
The shift in flora is most likely due to a number of factors that compromise host defense mecha-nisms. These include comorbidities, malnutrition, reduced levels of mucosal immunoglobulin A, increased production of proteases, exposed and denuded mucous membranes, elevated airway pH, and an increased number of airway receptors for bacteria as a result of acute illness and pre-vious antimicrobial use.