How to approach and treat VAP in ICU patients

Abstract

BackgroundVentilator-associated pneumonia (VAP) is one of the most frequent clinical problems in ICU with an elevated morbidity and costs associated with it, in addition to prolonged MV, ICU-length of stay (LOS) and hospital-length of stay. Current challenges in VAP management include the absence of a diagnostic gold standard; the lack of evidence regarding contamination vs. airway colonization vs. infection; and the increasing antibiotic resistance. We performed a Pubmed search of articles addressing the management of ventilator-associated pneumonia (VAP). Immunocompromised patients, children and VAP due to multi-drug resistant pathogens were excluded from the analysis. When facing a patient with VAP, it’s important to address a few key questions for the patient’s optimal management: when should antibiotics be started?; what microorganisms should be covered?; is there risk for multirresistant microorganisms?; how to choose the initial agent?; how microbiological tests determine antibiotic changes?; and lastly, which dose and for how long?. It’s important not to delay adequate treatment, since outcomes improve when empirical treatment is early and effective. We recommend short course of broad-spectrum antibiotics, followed by de-escalation when susceptibilities are available. Individualization of treatment is the key to optimal management.

Empirical antimicrobial therapy for probable v. directed therapy for possible ventilator-associated pneumonia in critically injured patients

“…[8] The recommendation is therefore to commence early broad-spectrum empirical therapy while awaiting microbiological confirmation, and then de-escalate as necessary. [9] Although minimising inappropriate prescriptions, this policy risks creating collateral damage and inducing bacterial resistance. Based on data showing that early appropriate administration of antimicrobials improves outcome in severe sepsis and septic shock, the same premise has been extrapolated to less-severe infections without proof of benefit.…”

“…[17] The only patients in whom combination therapy appears to be beneficial are those in septic shock. [9] In the presence of effective microbiological surveillance, it is possible to achieve adequate empirical antimicrobial therapy over 90% of the time with the initial empirical choice of a single agent. [18] The TICU at IALCH subscribes to stewardship and employs an empirical antimicrobial policy based on surveillance.…”

The effect of prior antimicrobial therapy for community acquired infections on the aetiology of early and late onset ventilator-associated pneumonia in a level I trauma intensive care unit

“…Recent hospitalisation to an acute care facility within the past 90 days with administration of intravenous antibiotics and residents in nursing homes or long-term care institutions are cited as high risk patients for bacterial resistance. 23 Chronic care institutions are especially problematic due to frequent transfers between hospitals and institutions and the excessive use of broad spectrum antimicrobials. 23 Cumulative exposure has also been documented as an independent risk factor for bacterial resistance but there are scant data, however, on the effect of a single course of antimicrobials for community acquired nonpneumonic infection and changes in aetiology and bacterial sensitivity patterns for early and late onset VAP.…”

“…23 Chronic care institutions are especially problematic due to frequent transfers between hospitals and institutions and the excessive use of broad spectrum antimicrobials. 23 Cumulative exposure has also been documented as an independent risk factor for bacterial resistance but there are scant data, however, on the effect of a single course of antimicrobials for community acquired nonpneumonic infection and changes in aetiology and bacterial sensitivity patterns for early and late onset VAP. Our data show that antimicrobials targeting community acquired infections alter the normal flora isolated from the first episode of VAP.…”

Emerging drugs for nosocomial pneumonia

“…Initial antibiotic should be active against likely pathogens; therefore its choice should be based on prior antibiotic exposure, patient co-morbidities, length of hospitalization and local epidemiology (1,9). The frequency of specific multidrug-resistant (MDR) pathogens causing VAP can vary by hospital, patient population, and prior exposure to antibiotics.…”