Refers to pneumonia occurring ≥ 48h after endotracheal intubation

Diagnosis of pneumonia is generally based on suggestive clinical features (cough, fever, sputum production, pleuritic chest pain, dyspnea) and a new chest x-ray infiltrate.

Note: there is NO gold standard for the definitive diagnosis of pneumonia.

  • The Respiratory Pathogen Panel (RPP) tests for 22 different respiratory pathogens by PCR, including atypical organisms and viruses, and can be ordered in patients in the ICU or upon approval from Medical Microbiology
  • In patients with cavitary pneumonia consider TB, fungal pathogens and Nocardia
  • In immunocompromised patients consider opportunistic pathogens such as PJP, CMV and fungal pathogens
  • Legionella urine antigen can be ordered on inpatients if interstitial/atypical X-ray findings or risk factors (hot tub exposure, travel)


Empiric Therapy

OR, IF Immunocompromised or known ESBL/AmpC


  • Known colonization
  • Necrotizing pneumonia
  • Recent influenza
  • Injection drug use
  • Broad spectrum antibiotic use in last 90 days

Duration of Therapy

7 days sufficient for the vast majority of VAP, including Pseudomonas. Guidelines no longer recommend prolonged treatment.

Therapy may be extended based on slow clinical improvement, or radiological and laboratory parameters.

Pseudomonas, Acinetobacter, Stenotrophomonas and Staph aureus HAP/VAP may require longer duration of treatment.


Empiric vancomycin can be discontinued if the nasal MRSA swab is negative, and no MRSA is identified in blood or sputum cultures

If microbiological results are POSITIVE, follow culture-directed therapy

Therapy Pearls

  • Refrain from treating Candida spp in the sputum, unless systemic candidiasis is suspected (e.g. neutropenia, transplant patients)
  • Cultures may continue to appear positive despite treatment in ventilated patients. Avoid re-culturing if the patient is clinically improving