image by: European Respiratory Society

HWN Suggests

Ventilator Associated Pneumonia (VAP)

The diagnosis of VAP continues to present challenges and pitfalls for the currently available clinical, radiological and microbiological diagnostic armamentarium... Mirroring the uncertainty surrounding VAP, our approach to it is a stepwise and recursive process. Avoidance of intubation when possible (e.g., using noninvasive ventilation). Orogastric tubes should be used rather than nasogastric tubes (the latter tend to cause sinusitis and increase the risk for VAP). Aggressive weaning off mechanical ventilation. Conservative blood transfusion policy (transfusion is a risk factor for VAP). Avoidance of very high (pulse-dose) steroids when possible, as this may increase the risk of nosocomial…

read full article

Articles of Interest

Antibiotics for ventilator‐associated pneumonia

Due to lack of studies, we could not evaluate the best antibiotic choice for VAP, but carbapenems as a class may result in better clinical cure than other tested antibiotics.

ATS/IDSA 2016 Clinical Practice Guidelines for the Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia:

In patients with suspected VAP, we recommend including coverage for S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli in all empiric regimens (strong recommendation, low-quality evidence). We suggest including an agent active against MRSA for the empiric treatment of suspected VAP only in patients with any of the following: a risk factor for antimicrobial resistance (Table 2), patients being treated in units where >10%–20% of S. aureus isolates are methicillin resistant, and patients in units where the prevalence of MRSA is not known (weak recommendation, very low-quality evidence). We suggest including an agent active against methicillin-sensitive S. aureus (MSSA) (and not MRSA) for the empiric treatment of suspected VAP in patients without risk factors for antimicrobial resistance, who are being treated in ICUs where <10%–20% of S. aureus isolates are methicillin resistant (weak recommendation, very low-quality evidence).

Ceftriaxone to prevent early ventilator-associated pneumonia

This well executed study provides evidence that an early, single dose of ceftriaxone prevents early VAP in patients with severe brain injury, as well as decreasing antibiotic and ventilation exposure, and mortality without safety concerns, and I will changing my practice accordingly.

IBCC chapter & cast – Ventilator Associated Pneumonia (VAP)

VAP is a perennial riddle in the intensive care unit. There are numerous murky diagnostic tests, but no single gold-standard diagnostic test. Consequently, we are usually left wondering whether or not the patient truly has a VAP. This makes VAP an unsatisfying diagnosis, as we are continually walking a blurred line between undertreatment and overtreatment.

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines

In an effort to minimize patient harm and exposure to unnecessary antibiotics and reduce the development of antibiotic resistance, we recommend that the antibiogram data be utilized to decrease the unnecessary use of dual gram-negative and empiric methicillin-resistant Staphylococcus aureus (MRSA) antibiotic treatment. We also recommend short-course antibiotic therapy for most patients with HAP or VAP independent of microbial etiology, as well as antibiotic de-escalation.

Summary of the international clinical guidelines for the management of hospital-acquired and ventilator-acquired pneumonia

HAP is the second most common hospital infection and has the highest crude mortality, while VAP is the most frequent cause of nosocomial infection in the ICU. Both types of pneumonia lengthen hospital stay and consume considerable health resources

Targeted antibiotic management of ventilator-associated pneumonia

Where initial therapy must be selected empirically, decisions are dependent on a detailed and up-to-date understanding of pathogens causing VAP locally. Such knowledge can only be achieved if high-quality microbiological surveillance information is readily available and communication between microbiologists and clinicians is fluid.

Treatment of ventilator-associated pneumonia

The antibiotic to be selected initially needs to be able to fight the epidemiological universal pathogens in the health care facility. In addition, antibiotic choice should also be based on the patient's prior antibiotic exposure, the patient's comorbidities, and the length of hospital stay. In this regard, special consideration should be given to patients with concurrent medical care-associated pneumonia, as pathogenic strains have a high probability of being multidrug-resistant pathogens. Risk factors for acquiring multidrug-resistant pathogens to investigate when initiating antibiotic selection include: recent hospitalization within 90 days, residency in a nursing home or long-term care facility recent history of intravenous antibiotic therapy, chemotherapy or wound care within the last 30 days of current infection, or the patient on hemodialysis.

Ventilator Associated Pneumonia

VAP applies to patients with an endoctracheal tube or a tracheostomy tube – does not include patients receiving non-invasive ventilation (NIV). common complication in ICU (15-20% incidence if >48h ventilation). a gold standard test for diagnosis does not exist.

Ventilator-associated pneumonia: pathobiological heterogeneity and diagnostic challenges

The diagnosis of VAP continues to present a clinical conundrum.. With a variance in diagnostic methods and reference standards, the existing literature offers a limited comparison to measure VAP’s progression and treatment response. Although considered a definitive marker, histological diagnosis is not viable for investigation for diagnosis and prognosis of VAP in ICU.

What Interventions Are Effective Against Ventilator-Associated Pneumonia?

Robust evidence was discovered to support the use of selective decontamination of the digestive tract and noninvasive ventilation in weaning from mechanical ventilation for preventing ventilator-associated pneumonia in critically ill patients.