Ventilator-Associated Pneumonia (VAP)
VAP - Clinical Pearls

VAP - Clinical Pearls

  • If the patient received an antibiotic in the past 3 months, choose an antibiotic from a different class, regardless of clinical success.

If MRSA risk factors, consider empiric coverage for MRSA

MRSA risk factors:

  • history of MRSA infection or colonization
  • household contact with a MRSA colonized individual
  • IV drug use
  • crowded living conditions (e.g., homelessness, incarcerated persons)
  • recent travel to or residing in an MRSA endemic region or community
  • If history of infection or colonization with Gram-negative bacilli producing AmpC or Extended Spectrum beta-lactamases (ESBL), empiric use of meropenem is encouraged (may consider fluoroquinolones if susceptibility known, stable and no risk factors).
  • Consider for patients who have septic shock, increasing ventilatory support requirements or structural lung disease (e.g., bronchiectasis, cystic fibrosis) (see empiric treatment)
  • Used to maximize the likelihood of having at least one active antimicrobial (due to increased risk of resistance with Pseudomonas).
  • Re-evaluate use after 48 hours.  If Pseudomonas is isolated, step-down to monotherapy (according to susceptibility data).
    • Maintaining double coverage once susceptibilities are known is not required
  • Use of aminoglycosides (e.g., tobramycin and gentamicin) as monotherapy for the treatment of pneumonia is NOT recommended (even if susceptibility is confirmed).
  • DO NOT use DAPTOmycin to treat pneumonia; DAPTOmycin is inactivated by pulmonary surfactant.
  • If MRSA infection, use vancomycin (or linezolid if vancomycin is ineffective or inappropriate)
  • Defined as fever with no other recognizable cause, with new or increased sputum production, positive ETA culture yielding a new bacteria, and no radiographic evidence of nosocomial pneumonia.
  • Should not routinely be treated.
  • Only consider initiating antimicrobial therapy if clinical deterioration (e.g., progressive hypoxemia).
  • To avoid prolonged use of broad-spectrum antibiotics, it is essential to de-escalate therapy according to the results of microbiologic analyses