Key Points
- Stabilize ABCs; begin targeted evaluation without delaying life-saving therapy.
- Use system-specific risk tools to guide testing and disposition.
- Order high-yield tests first; escalate imaging when indicated.
- Start evidence-based initial therapy and reassess frequently.
Algorithm
- Primary survey and vitals; IV access and monitors.
- Focused history/physical; identify red flags and likely etiologies.
- Order system-appropriate labs and imaging (see Investigations).
- Initiate guideline-based empiric therapy (see Pharmacology).
- Reassess response; arrange consultation and definitive management.
Clinical Synopsis & Reasoning
For Hap Vap Adult, frame the differential by acuity and pathophysiology, then align diagnostics to the leading hypotheses. Prioritize stabilization while obtaining high‑yield studies such as CBC (Inflammation/infection), Lactate (Hypoperfusion), Blood cultures (Pathogen ID). Incorporate bedside imaging and targeted labs to define severity and identify complications; synthesize results with clinical trajectory to refine the working diagnosis and disposition needs.
Treatment Strategy & Disposition
Initiate disease‑directed therapy alongside supportive care, titrating to objective response. Pharmacologic options commonly include Broad-spectrum antibiotics. Use validated frameworks (e.g., Common MDR Risk Factors) to guide escalation and site of care. Address precipitating factors, de‑escalate empiric therapies with data, and arrange follow‑up for monitoring and risk‑factor modification; admit patients with instability, high risk of deterioration, or needs for close monitoring.
Epidemiology / Risk Factors
- Immunosuppression, devices; recent hospitalization
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CBC | Inflammation/infection | Leukocytosis/leukopenia | |
| Lactate | Hypoperfusion | Elevated | Trend |
| Blood cultures | Pathogen ID | Positive/negative | Before antibiotics if feasible |
Common MDR Risk Factors
| Domain | Examples |
|---|---|
| Recent antibiotics | Within prior 90 days |
| Healthcare exposure | Residence in units with high MRSA/Pseudomonas prevalence |
| Ventilation factors | Longer duration of ventilation |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Cefepime | 4th-gen cephalosporin | Hours | Anti-pseudomonal coverage | Neurotoxicity (AKI) |
| Piperacillin-tazobactam | β-lactam/β-lactamase inhibitor | Hours | Broad gram-neg incl. Pseudomonas | Allergy, AKI |
| Vancomycin | Cell-wall inhibition | Hours | MRSA coverage | Nephrotoxicity; monitor trough/AUC |
| Levofloxacin | Fluoroquinolone | Hours | Add/alternative gram-negative/atypicals | QT, tendinopathy |
| De-escalation per cultures | N/A | Days | Narrow once ID/AST known | Resistance stewardship |
Prognosis / Complications
- Depends on host and source control; sepsis/organ failure risk
Patient Education / Counseling
- Explain red flags and when to seek emergent care.
- Reinforce medication adherence and follow-up plan.
Notes
Implement ventilator bundle (elevation, sedation minimization, oral care). Consider inhaled antibiotics only in select MDR pathogens with poor penetration.