Guidelines
Ventilator-Associated Pneumonia

Ventilator-Associated Pneumonia

Clinical Considerations

Pneumonia occurring > 48 hours after endotracheal intubation

  • Should be obtained prior to starting or changing antibiotics
  • Endotracheal aspirate or bronchoscopic specimen if possible
  • Antibiotic selection is based on local prevalence of pathogen resistance and risk factors for MDR pathogens
  • MRSA coverage recommended as MRSA rate >10%
  • Double coverage for Pseudomonas aeruginosa recommended when risk factors for antimicrobial resistance are present:
    • Prior IV antibiotic use within 90 days
    • Acute renal replacement therapy prior to VAP onset
    • Septic shock at time of VAP
    • ≥5 days of hospitalization prior to VAP occurrence
    • ARDS preceding VAP
    • Structural lung disease (i.e. bronchiectasis or cystic fibrosis)
  • If Culture Positive
    • De-escalate therapy as soon as culture results available
      • D/C vancomycin if MRSA not isolated
      • Gram-negative coverage can be reduced to single agent in most cases
  • If Culture Negative
    • Consider alternative sources and narrow therapy
  • If MRSA nares screen is negative and respiratory culture negative/not available
    • Consider D/C vancomycin
      • > 95% negative predictive value from numerous MRSA pneumonia studies (96.7% for MRSA VAP)
  • Enterococci and Candida often isolated from sputum
    • Considered colonizing organisms
    • Do NOT treat
  • Benefits studied in treatment of Pseudomonas infections show conflicting data
  • Benefits only shown using combination of a beta-lactam plus an aminoglycoside, which may increase risk of nephrotoxicity
  • For patients with HAP/VAP due to P. aeruginosa and results of antibiotic susceptibility testing are known:
    • Monotherapy (eg. cefepime) recommended for those NOT in septic shock/high risk for death
    • Combination therapy suggested for those who remain in septic shock or at a high risk for death

Microbiology

More Information

  1. IDSA Guidelines for HAP/VAP. Clin Infect Dis 2016.
  2. Giancola SE, et al. Clinical utility of a nasal swab methicillin-resistant Staphylococcus aureus polymerase chain reaction test in intensive and intermediate care unit patients with pneumonia. Diag Microbiol Infect Dis 2016.
  3. Chan JD, et al. Active surveillance cultures of methicillin-resistant Staphylococcus aureus as a tool to predict methicillin-resistant S. aureus ventilator-associated pneumonia. Crit Care Med 2012;40:1437-1442.