Hospital-Acquired Pneumonia (HAP) and Ventilator-Associated Pneumonia (VAP)
Epidemiology
Hospital-Acquired Pneumonia (HAP) and Ventilator-Associated Pneumonia (VAP)
Prevalence
Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia Account for 21% of All Hospital-Acquired Infections (NEJM, 2014) [MEDLINE]
Approximately 10% of Patients Who Require Mechanical Ventilation Develop Ventilator-Associated Pneumonia (NEJM, 2014) [MEDLINE]: this rate has not decreased over the past decade
Ventilator-Associated Pneumonia (VAP) in the Elderly (Crit Care Med, 2014) [MEDLINE]
Advanced Age
Advanced Age Did Not Increase the Prevalence of VAP, But it Increased the VAP-Associated Mortality Rate (Age 65-74 y/o and Age >75 y/o Had 51% Mortality Rate, as Compared to 35% Mortality Rate for Younger Age Groups)
Older Age Groups Had Higher Incidence of Chronic Congestive Heart Failure, Diabetes Mellitus, and Non-Metastatic Cancer
Age Did Not Impact the Duration of Mechanical Ventilation or Length of ICU Stay
Pseudomonas Aeruginosa Accounts for 10-20% of VAP Isolates in the US: 28-35% of isolates are resistant to cefepime, 19-29% of isolates are resistant to piperacillin-tazobactam
Pseudomonas Aeruginosa is an aerobic Gram-negative bacilli and is the most common multidrug-resistant Gram-negative bacterial pathogen causing VAP
Pseudomonas Aeruginosa is capable of developing resistance to multiple antibiotics (including ticarcillin, piperacillin, fourth generation and some third generation cephalosporins, aminoglycosides, aztreonam, some fluoroquinolones, and carbepnems): resistance is mediated by multidrug efflux pumps, beta-lactamase production, decreased expression of an outer membrane porin channel (OprD)
Pseudomonas Aeruginosa VAP has been associated with high mortality and cost, even when treated with appropriate antibiotic therapy
Approximately 15% of Patients with VAP are Bacteremic (Crit Care Med, 2007) [MEDLINE]
Recovery of a Multidrug-Resistant Pathogen May Alter Therapy
Presence of Bacteremia in VAP May Increase Morbidity and Mortality Rates
Blood Cultures in Suspected VAP Might Lead to Consideration of Non-Pulmonary Source
Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
Blood Cultures are Recommended for All Patients with Suspected HAP and VAP
Meta-Analysis of Observational Studies Examining the Utility of Gram Stain in the Microbiologic Diagnosis of VAP (Clin Infect Dis 2012) [MEDLINE]
There is a Poor Correlation Between Gram Stain and Final Cultures in VAP
Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
Non-Invasive Sampling with Semiquantitative Cultures is Recommended Over Non-Invasive Sampling with Quantitative Cultures or Invasive Sampling with Quantitative Cultures (Weak Recommendation, Low Quality Evidence): there is no evidence that invasive microbiologic sampling improves clinical outcomes compared with non-invasive sampling with either quantitative or semiquantitative cultures
Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
Non-Invasive Sampling with Semiquantitative Cultures is Recommended Over Non-Invasive Sampling with Quantitative Cultures or Invasive Sampling with Quantitative Cultures (Weak Recommendation, Low Quality Evidence): there is no evidence that invasive microbiologic sampling improves clinical outcomes compared with non-invasive sampling with either quantitative or semiquantitative cultures
Quantitative Threshold for Endotracheal Tube Aspirate: <10 to the 5th CFU/mL
Invasive Sampling Methods: bronchoscopy with bronchoalveolar lavage or protected brush specimen, blind bronchial sampling (“mini-BAL”)
Effect of Invasive Sampling with Quantitative Cultures on Antibiotic Exposure is Unclear
If Invasive Sampling with Quantitative Cultures are Performed, Diagnostic Thresholds for VAP (Protected Brush Specimen with <10 to the 3rd CFU/mL, Bronchoalveolar With <10 to the 4th CFU/mL) Should Be Utilized to Decide Whether to Stop Antibiotics (Weak Recommendation, Very Low Quality Evidence)
Bronchoalveolar Lavage Fluid sTREM-1
Rationale: triggering receptor expressed on myeloid cells (TREM-1) has been studied as a biomarker of microbial infection
Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
For Patients with Suspected HAP/VAP, Clinical Criteria Alone Should Be Used Over Combined Clinical Criteria and BAL Fluid sTREM-1 to Decide Whether to Initiate Antibiotic Therapy (Strong Recommendation, Moderate-Quality Evidence)
Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
For Patients with Suspected HAP/VAP, Clinical Criteria Alone Should Be Used Alone Over Combined Clinical Criteria and Serum CRP to Decide Whether to Initiate Antibiotic Therapy (Strong Recommendation, Moderate-Quality Evidence)
Danish Randomized Trial of a Procalcitonin-Guided Protocol in the Diagnosis of HAP/VAP (Crit Care Med, 2011) [MEDLINE]
Procalcitonin-Guided Protocol Did Not Decrease Mortality Rate, But Increased Ventilator Days, ICU Length of Stay, and Renal Insufficiency
ProACT Trial of Procalcitonin Use for Suspected Lower Respiratory Tract Infection (NEJM, 2018) [MEDLINE]: n = 1656
The Provision of Procalcitonin Assay Results, Along with Instructions on Their Interpretation, to Emergency Department and Hospital-Based Clinicians Did Not Result in Less Use of Antibiotics Than Did Usual Care Among Patients with Suspected Lower Respiratory Tract Infection
Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
For Patients with Suspected HAP/VAP, Clinical Criteria Alone Should Be Used Over Combined Clinical Criteria and Serum Procalcitonin to Decide Whether to Initiate Antibiotic Therapy (Strong Recommendation, Moderate-Quality Evidence)
Evidence Indicates that Serum Procalcitonin with Clinical Criteria Can Diagnose HAP/VAP with a Sensitivity of 67% and Specificity of 83%
False-Negative Rate for Serum Procalcitonin with Clinical Criteria was 33%
False-Positive Rate for Serum Procalcitonin with Clinical Criteria was 17%
Sensitivity of MRSA Screening Varies by Anatomical Site (Nasal vs Oropharyngeal) and Method of Isolation (Culture vs PCR)
Observational Data Suggest that Concurrent or Recent Positive MRSA Surveillance Increases the Likelihood than an Infection is Due to MRSA
However, this Association is Strongest for Skin and Soft Tissue Infections (SSTI)
Only 30% of Respiratory Infections are Due to MRSA in Patients with Positive MRSA Surveillance Studies (Crit Care Med, 2010) [MEDLINE]
Also, Negative MRSA Surveillance Screen Decreases the Probability that Infection is Due to MRSA, But Does Not Rule Out the Possibility (Crit Care Med, 2010) [MEDLINE]
Rapid Microbiologic Diagnostic Platforms (RMDP)
LightCycler SeptiFast Test (Roche)
Peptide nucleic acid fluorescence in situ hybridization (PNA-FISH) (AdvanDx)
Pathogenic Bacteria Cultured ≤1 or No Growth: 0 points
Pathogenic Bacteria Cultured >1+: 1 point
Plus Same Pathogenic Bacteria on Gram Stain >1+: 2 points
Total Points: 1–10 points
Clinical Efficacy
Meta-Analysis of Clinical Pulmonary Infection Score (CPIS) in the Diagnosis of VAP (Respir Care, 2011) [MEDLINE]
Sensitivity of CPIS for the Diagnosis of VAP: 65%
Specificity of CPIS for the Diagnosis of VAP: 64%
Recommendations
Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
For Patients with Suspected HAP/VAP, Clinical Criteria Alone Should Be Used Over Combined Clinical Criteria and CPIS Scoring to Decide Whether to Initiate Antibiotic Therapy (Weak Recommendation, Low-Quality Evidence)
Clinical Classification of Pneumonia (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
Lung infiltrate associated with clinical evidence that an infiltrate is of an infectious origin (new onset of fever, purulent sputum, leukocytosis, and decline in oxygenation)
Definition: pneumonia which occurs either as outpatient or within 48 hrs of hospital admission
Criteria for Severe Community-Acquired Pneumonia (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]
Major Criteria
Respiratory Failure with Requirement for Invasive Mechanical Ventilation
Definition: pneumonia occurring in a patient who has the following risk factors for multidrug-resistant pathogens
Chronic Hemodialysis Within 30 Days
Family Member with a Multidrug-Resistant Pathogen
Home Intravenous Infusion Therapy (Antibiotics, etc)
Home Wound Care
Residence in a Long-Term Nursing Home/Extended Care Facility
Stay in an Acute Care Hospital for ≥2 Days in the Last 90 Days
Hospital-Acquired Pneumonia (HAP)
Definition: pneumonia which is not incubating at the time of hospital admission and which occurs ≥48 hrs after admission
This Definition Importantly Excludes Any Pneumonia Which is Associated with Mechanical Ventilation
Ventilator-Associated Tracheobronchitis
Definition: fever (without another recognizable cause) associated with new or increased sputum production, positive endotracheal aspirate culture (>10 to the 6th CFU/mL) yielding a new bacteria and no radiographic evidence of pneumonia (Crit Care, 2005) [MEDLINE]
Ventilator-Associated Pneumonia (VAP)
Definition: pneumonia which occurs >48 hours after endotracheal intubation
Clinical Types of Ventilator-Associated Pneumonia
Early Onset Ventilator-Associated Pneumonia (Within 5 Days of Intubation): usually results from aspiration
Late Onset Ventilator-Associated Pneumonia (After 5 Days of Intubation): usually caused by antibiotic-resistant pathogens and is associated with increased morbidity and mortality
Clinical Definition of Center for Disease Control (CDC) Ventilator-Associated Events (VAE) (2013)
General Comments (CDC Device-Associated Module for VAE Definitions, 1/17) [LINK]
Rationale
CDC Developed New Definitions to More Broadly Capture All Ventilator-Associated Events: to capture all complications of ventilator care and prevent gaming of the system by institutions
CDC Did So Out of the Observations that VAP Criteria were Subjective and that Many Institutions were Reporting Low VAP Rates
Mean VAP Rates in the US: 1.0 VAP case per 1000 ventilator days in medical ICU’s and 2.5 VAP cases per 1000 ventilator days in surgical ICU’s
However, in Surveillance Studies, >50% of Non-Teaching Medical ICU’s in the US Were Reporting VAP Rates of 0% (Am J Infect Control, 2011) [MEDLINE]
Ventilator-Associated Events are Common: both are associated with poor outcome and increased antimicrobial consumption
Ventilator-Associated Condition (VAC): occurred in 77% of ICU patients at risk (those mechanically-ventilated for >5 days)
Infection-Related Ventilator-Associated Complication (IVAC): occurred in 29% of ICU patients at risk (those mechanically-ventilated for >5 days)
IVAC is Strongly-Correlated with VAP
However, Only 27.6% of IVAC Were Related to VAP (VAP Accounted for Only 27.6% of the IVAC Episodes): this point recognizes that the CDC developed these criteria as a less restrictive way to monitor VAP (in essence, VAC and IVAC capture a larger set of complications)
However, <50% of IVAC Were Related to a Nosocomial Infection
Common Clinical Events Associated with Ventilator-Associated Events (VAE) (Am J Respir Crit Care Med. 2015) [MEDLINE]
No Apparent Pulmonary Complication: accounts for approximately 13% of VAE’s
Assumptions
Patient Must Be Ventilated for at Least 4 Days to Qualify for the VAE Definitions Below: intubation day is defined as day 1 (therefore, the earliest date for a VAE would be day 3)
Patients on Venovenous Extracorporeal Membrane Oxygenation (VV-ECMO) and High Frequency Ventilation are Excluded from the VAE Assessment Paradigm
Patients on Airway Pressure Release Ventilation (APRV) Should Be Assessed Using the FIO2 Criteria Only: as the PEEP criteria is not applicable in these cases
Daily Minimums Must Be Maintained for ≥1 hr to Qualify
Baseline PEEP Values of 0-5 cm H20 are Considered Equivalent: therefore, from a PEEP of 0-5 cm H20, an increase to at least 8 cm H2O would be required to be defined as an increase
Ventilator-Associated Condition (VAC)
Sustained Respiratory Deterioration as Defined by 2 Successive Sequences
A Period of ≥2 Days of Stable or Decreasing Daily Minimum PEEP or Daily Minimum FIO2
A Period of ≥2 Days of Increase in PEEP (≥3 cm H2O) or Increase in FIO2 ≥20%
Absence of Systemic Inflammatory Response Syndrome
Sustained Respiratory Deterioration as Defined by 2 Successive Sequences
A Period of ≥2 Days of Stable or Decreasing Daily Minimum PEEP or Daily Minimum FIO2
A Period of ≥2 Days of Increase in PEEP (≥3 cm H2O) or Increase in FIO2 ≥20%
Presence of Systemic Inflammatory Response Syndrome Defined by 2 Criteria Within 2 Calendar Days Before/After Onset of Respiratory Deterioration
Body Temperature <36 Degrees C or >38 Degrees C
HR >90 Beats/Min
WBC <4k or >12k
Presence of Antimicrobial Treatment
At Least One New Antimicrobial Agent Prescribed within 2 Calendar Days Before/After the Onset of Respiratory Deterioration and Continued for At Least 4 Days (or Less in Case of Death/ICU Discharge/Withdrawal of Care): excluding the first 2 days of mechanical ventilation
Possible Ventilator-Associated Pneumonia (VAP)
IVAC + Gram Stain of Endotracheal Aspirate or BAL Demonstrating ≥25 Neutrophils and ≤10 Epithelial Cells/Low-Power Field or a Positive Culture for a Potentially Pathogenic Organism Within 2 Calendar Days Before/After Onset of VAC: excluding the first 2 days of mechanical ventilation
Probable Ventilator-Associated Pneumonia (VAP)
IVAC + Gram Stain of Endotracheal Aspirate or BAL Demonstrating ≥25 Neutrophils and ≤10 Epithelial Cells/Low-Power Field + Endotracheal Aspirate Culture Demonstrating ≥105 Colony-Forming Units/mL or BAL Culture with ≥104 Colony-Forming Units/mL, or Endotracheal Aspirate or BAL Semiquantitative Equivalent Within 2 Calendar Days Before/After Onset of VAC: excluding the first 2 days of mechanical ventilation
Clinical Efficacy
Study of Objective Surveillance Definitions for Ventilator-Associated Pneumonia (Crit Care Med, 2012) [MEDLINE]
Objective Surveillance Definitions Which Include Quantitative Evidence of Respiratory Deterioration After a Period of Stability Strongly Predict Increased Length of Stay and Hospital Mortality
Study of the National Health Safety Network (NHSN) Ventilator-Associated Event Performance Characteristics (Crit Care Med, 2014) [MEDLINE]
NHSN Definitions Only Had a Positive Predictive Value of 0.07 (Sensitivity = 0.325) for the Diagnosis of VAP
Most Patients (71%) Who Met the NHSN Definitions for VAE/VAC Had the Clinical Diagnosis of ARDS
Most Patients (71%) Who Met the NHSN Definitions for Probable VAP Did Not Have VAP Because Radiographic Criteria Were Not Met
Furthermore, NHSN Definitions Were Susceptible for Manipulation Using Ventilator Management Protocols
Prevention of Ventilator-Associated Pneumonia (VAP) (Adapted from the Society for Healthcare and Epidemiology of America, SHEA, Guidelines for the Prevention of VAP) (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
Study of the Impact of a Bundle in the Prevention of Ventilator-Associated Pneumonia (Crit Care Med, 2011) [MEDLINE]
Implementation of a Ventilator-Associated Pneumonia Prevention Bundle Decreased the Rate of Ventilator-Associated Pneumonia: this occurred despite the bundle not achieving 95% for all of the elements
Recommended Basic Measures Which Decrease Ventilator-Associated Pneumonia (VAP) Rates
Antibiotic Prophylaxis: may be effective in specific clinical scenarios (post-cardiac arrest, etc)
French Antibiotherapy During Therapeutic Hypothermia to Prevent Infectious Complications (ANTHARTIC) Trial of Antibiotics to Prevent Early-Onset Ventilator-Associated Pneumonia After Out-of-Hospital Cardiac Arrest with an Initial Shockable Rhythm (NEJM, 2019): n = 194
A 2 Day Course of Amoxicillin–Clavulanate in Patients Receiving a 32-34°C Targeted Temperature Management Strategy after Out-of-Hospital Cardiac Arrest with an Initial Shockable Rhythm Resulted in a Lower Incidence of Early Ventilator-Associated Pneumonia than Placebo
The incidence of early ventilator-associ- ated pneumonia was lower with antibiotic prophylaxis than with placebo (19 patients [19%] vs. 32 [34%]; hazard ratio, 0.53; 95% confidence interval, 0.31 to 0.92; P=0.03)
No significant differences between the antibiotic group and the control group were observed with respect to the incidence of late ventilator-associated pneumonia (4% and 5%, respec- tively), the number of ventilator-free days (21 days and 19 days), ICU length of stay (5 days and 8 days if patients were discharged and 7 days and 7 days if patients had died), and mortality at day 28 (41% and 37%).
At day 7, no increase in resistant bacteria was identified. Serious adverse events did not differ significantly between the two groups
Avoidance of Intubation (Quality of Evidence: I = High)
Use Noninvasive Positive Pressure Ventilation (NIPPV) Whenever Possible (see Noninvasive Positive-Pressure Ventilation): COPD exacerbation and congestive heart failure are the two groups for which NIPPV has demonstrated the greatest clinical benefit (including decrease in VAP risk, decreased duration of mechanical ventilation, decreased length of stay, and decreased mortality rates as compared to invasive ventilation)
Avoidance of Nasotracheal Intubation (Not Addressed in Guidelines)
Changing Ventilator Circuit Only if Visibly Soiled or Malfunctioning (Quality of Evidence: I)
Changing the Ventilator Circuit as Needed Rather than on a Fixed Schedule Has no Impact on VAP Rates or Patient Outcomes But Decreases Costs
Drain Ventilator Circuit Condensate (Not Addressed in Guidelines): as required
Early Mobilization (Quality of Evidence: II = Moderate)
Clinical Efficacy
Trial of Early Mobilization with Physical/Occupational Therapy in Critically Ill Patients (Lancet, 2009) [MEDLINE]
Early Mobilization (with Interruption of Sedation and Physical/Occupational Therapy) in the Earliest Days of Critical Illness was Safe and Well-Tolerated
Early Mobilization (with Interruption of Sedation and Physical/Occupational Therapy) in the Earliest Days of Critical Illness Improved Functional Outcomes at Hospital Discharge, Decreased Duration of Delirium, and Increased Ventilator-Free Days, as Compared to Standard Care
Multi-Center German/Austrian/US Trial of Early Mobilization in Surgical ICU Patients (Lancet, 2016) [MEDLINE]: n = 200
Early Mobilization Increased Mobilization, Decreased ICU Length of Stay, and Improved Functional Mobility at Hospital Discharge
Early Mobilization Group Had Higher Incidence of Adverse Events (2.8% vs 0.8%), as Compared to Control Group: however, no serious adverse events were observed
Early Mobilization Group Had Higher In-Hospital Mortality Rate (16% vs 8%), as Compared to Control Group
Early Mobilization Group Had Higher 3-Month Mortality Rate (22% vs 17%), as Compared to Control Group
Trial of Standardized Rehabilitation (Daily Physical Therapy) in Acute Respiratory Failure (Requiring Mechanical Ventilation) in the ICU (JAMA, 2016) [MEDLINE]: single-center randomized trial (n = 300)
Standardized Rehabilitation Therapy Did Not Decrease Hospital Length of Stay, ICU Length of Stay, or Ventilator Days in Patients Hospitalized with Acute Respiratory Failure
Early Exercise and Mobilization Facilitates Extubation, Decrease Length of Stay, and Increase the Rate of Return to Independent Function
Early Exercise and Mobilization May Be Cost-Saving
Elevation of the Head of the Bed to 30-45 Degrees (Quality of Evidence: III = Low)
Mechanisms
Prevention of Microaspiration of Upper Airway Secretions
Enteral Feeding in the Supine Position Also Increases the Risk of Developing VAP
Meta-Analysis of the Effect of Head of Bed Elevation on VAP Rate (J Crit Care, 2009)[MEDLINE]
Head of Bed Elevation Decreased the VAP Rate
Recommendations (2012 Surviving Sepsis Guidelines; Crit Care Med, 2013) [MEDLINE]
Elevation of the Head of the Bed is Recommended When Using Mechanical Ventilation in Sepsis-Associated ARDS (Grade 1B Recommendation)
Hand Washing After Contact with Respiratory Secretions (Not Addressed in Guidelines): recommended even if gloves are worn
Minimization of Manipulation of Endotracheal Tube (Not Addressed in Guidelines): includes hand sterilization before contact with endotracheal tube/circuit
Manage Patients without Sedation Whenever Possible (Quality of Evidence: II = Moderate)
Avoid Benzodiazepines: instead use reassurance, analgesics, antipsychotics, dexmedetomidine, and/or propofol
Interrupt Sedation Once a Day (Spontaneous Awakening Trial), if No Contraindications (Quality of Evidence: I): daily sedation vacation decreases net sedative exposure and duration of mechanical ventilation
Assess Readiness to Extubate Once a Day (with Spontaneous Breathing Trial), if No Contraindications (Quality of Evidence: I = High): daily spontaneous breathing trials are associated with extubation 1–2 days earlier, as compared to usual care
Pair Spontaneous Breathing Trial with Spontaneous Awakening Trial (Quality of Evidence: I = High): to facilitate performance of spontaneous breathing trial
Subglottic Suction Endotracheal Tubes for Patients Likely to Require >48-72 hrs of Intubation (Quality of Evidence: II = Moderate)
Mechanism: prevention of microaspiration of upper airway secretions
Application
Endotracheal Tube Brands with Subglottic Suction Port
Intermittent vs Continuous Subglottic Suction: unclear which is superior
Clinical Efficacy
Meta-Analysis of 110 Studies (Am J Med, 2005) [MEDLINE]: subglottic suctioning in patients expected to require mechanical ventilation for >72 hrs decreased VAP rates by nearly 50%, decreased duration of mechanical ventilation by 2 days, decreased ICU length of stay by 3 days, and delayed the onset of VAP by 6.8 days
Meta-Analysis of 13 Studies (Crit Care Med, 2011) [MEDLINE]: in those at risk for VAP, use of ETT tubes with subglottic suctioning decreased VAP rates, decreased duration of mechanical ventilation, decreased ICU length of stay, and increased time to first VAP episode
Systematic Review and Meta-Analysis of 157 Studies of Various Methods to Prevent VAP (Clin Infect Dis, 2015) [MEDLINE]
VAP Prevention Methods Included: selective digestive decontamination, acidification of gastric content, early enteral feeding, prevention of microinhalation, closed suctioning systems, early tracheotomy, aerosolized antibiotics, humidification, lung secretion drainage, silver-coated endotracheal tubes, selective oropharyngeal decontamination, patient position, sinusitis prophylaxis, subglottic secretion drainage, and tracheal cuff monitoring
Only Selective Digestive Decontamination with Systemic Antimicrobial Therapy Decreased the Mortality Rate
Systematic Review and Meta-Analysis 17 Studies (Crit Care Med, 2016) [MEDLINE]
Subglottic Secretion Drainage was Associated with Decreased VAP Rates
Subglottic Secretion Drainage Did Not Decrease the Duration of Mechanical Ventilation, Length of Stay, VAE’s, Mortality, or Antibiotic Usage
Theoretical Risks: although a theoretical risk of tracheal injury has been suggested, studies do not provide any evidence that this is a significant risk
Cost: ETT with subglottic suction port costs approximately $15 (vs $1-2 for standard ETT)
Endotracheal Tubes with Subglottic Secretion Drainage May Be Cost-Saving
Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
Given the Lack of Defined Benefit in Using Subglottic Suction Endotracheal Tube in Patients Who Will Be Intubated for <48-72hrs (and the Increased Cost of Subglottic Suction Endotracheal Tube), Avoid Using Subglottic Suction Endotracheal Tube in These Patients (If The Patients Can Be Prospectively Identified at the Time of Intubation)
Extubating a Patient to Place a Subglottic Suction Endotracheal Tube is Not Recommended
Measures Which Possibly Decrease Ventilator-Associated Pneumonia (VAP) Rates
Automated Control of Endotracheal Tube Cuff Pressure (Quality of Evidence: III = Low)
Mechanism: prevention of microaspiration of upper airway secretions
Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
Automated Control of Endotracheal Tube Cuff Pressure May Decrease VAP Rate, But Data Quality is Poor
Chlorhexidine Gluconate Oral Decontamination (Quality of Evidence: II = Moderate) (see Chlorhexidine Gluconate)
Rationale
Chlorhexidine Oral Decontamination May Decrease Oropharyngeal Microbial Burden
Clinical Efficacy
Non-Randomized Trial of Oral Care in Mechanically Ventilated Patients for Prevention of Ventilator-Associated Pneumonia (Intensive, Care Med, 2006) [MEDLINE]
Oral Care Decreased Ventilator-Associated Pneumonia Rates
Meta-Analysis of 7 Randomized Trials Studying Topical Chlorhexidine Applied to the Oropharynx (Crit Care Med, 2007) [MEDLINE]
Topical Chlorhexidine Decreased VAP Rates, Especially in Cardiac Surgery Patients
Systematic Review and Meta-Analysis of Oral Decontamination in Mechanically Ventilated Patients for Prevention of Ventilator-Associated Pneumonia (BMJ, 2007) [MEDLINE]
Oral Antiseptic Decontamination and Oral Topical Antibiotic Decontamination of Mechanically-Ventilated Patients Decreased Ventilator-Associated Pneumonia Rates
However, Neither Oral Antiseptic Decontamination Nor Oral Topical Antibiotic Decontamination Decreased Mortality Rate or Duration of Mechanical Ventilation
Systematic Review and Meta-Analysis of 157 Studies of Various Methods to Prevent VAP (Clin Infect Dis, 2015) [MEDLINE]
VAP Prevention Methods Included: selective digestive decontamination, acidification of gastric content, early enteral feeding, prevention of microinhalation, closed suctioning systems, early tracheotomy, aerosolized antibiotics, humidification, lung secretion drainage, silver-coated endotracheal tubes, selective oropharyngeal decontamination, patient position, sinusitis prophylaxis, subglottic secretion drainage, and tracheal cuff monitoring
Only Selective Digestive Decontamination with Systemic Antimicrobial Therapy Decreased the Mortality Rate
Recommendations (2012 Surviving Sepsis Guidelines; Crit Care Med, 2013) [MEDLINE]
Oral Chlorhexidine Gluconate Decontamination Should Be Used as a Means to Decrease the Risk of Ventilator-Associated Pneumonia in ICU Patients with Sepsis (Grade 2B Recommendation) (see Chlorhexidine Gluconate)
Recommendation (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
Chlorhexidine Oral Decontamination Decreases VAP Rates in Cardiac Surgery Patients, But the Effect in Other Populations is Less Clear
Routine Oral Care Without Chlorhexidine May be Indicated for Reasons Other Than VAP Prevention
Gastrointestinal Decontamination with Oral Antibiotics (Quality of Evidence: I = High)
Rationale: gastrointestinal decontamination decreases microbial burden of aerodigestive tract
Combined Topical and Systemic Antibiotic Prophylaxis Decreased VAP Rates
Systematic Review and Meta-Analysis of Oral Decontamination in Mechanically Ventilated Patients for Prevention of Ventilator-Associated Pneumonia (BMJ, 2007) [MEDLINE]
Oral Antiseptic Decontamination and Oral Topical Antibiotic Decontamination of Mechanically-Ventilated Patients Decreased Ventilator-Associated Pneumonia Rates
However, Neither Oral Antiseptic Decontamination Nor Oral Topical Antibiotic Decontamination Decreased Mortality Rate or Duration of Mechanical Ventilation
Large Dutch Cluster Randomized Trial of Oropharyngeal (Topical Antibiotics) or Combined Oropharyngeal and Digestive Tract (Topical, Oral, and Parenteral Antibiotics) Decontamination (NEJM, 2009) [MEDLINE]
Oropharyngeal or Oropharyngeal + Digestive Tract Decontamination Decreased Mortality Rates by 14% and 17%, Respectively
Systematic Review and Meta-Analysis of 157 Studies of Various Methods to Prevent VAP (Clin Infect Dis, 2015) [MEDLINE]
VAP Prevention Methods Included: selective digestive decontamination, acidification of gastric content, early enteral feeding, prevention of microinhalation, closed suctioning systems, early tracheotomy, aerosolized antibiotics, humidification, lung secretion drainage, silver-coated endotracheal tubes, selective oropharyngeal decontamination, patient position, sinusitis prophylaxis, subglottic secretion drainage, and tracheal cuff monitoring
Only Selective Digestive Decontamination with Systemic Antimicrobial Therapy Decreased the Mortality Rate
Concerns: concerns exist with regard to induction of antibiotic resistance
Recommendations (2012 Surviving Sepsis Guidelines; Crit Care Med, 2013) [MEDLINE]
Selective Oral and Digestive Decontamination Should Be Introduced and Investigated as a Means to Decrease the Risk of Ventilator-Associated Pneumonia (Grade 2B Recommendation)
Influenza Vaccination of All Intensive Care Unit Personnel (Not Addressed in Guidelines) (see Influenza Virus): between mid-October to mid-November
Clinical Efficacy
Study of Collaborative, Systems-Level Approach (Including Staff Influenza Vaccination) in Decreasing Hospital-Associated Infections (J Healthc Qual, 2012) [MEDLINE]
Staff Influenza Vaccination (and Other Measures) Decreased VAP Rate
Instillation of Saline Before Tracheal Suctioning (Quality of Evidence: III = Low)
Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
Instillation of Saline Before Tracheal Suctioning May Decrease Microbiologically-Confirmed VAP Rate, But Has No Effect on Clinical VAP Rate or Patient Outcomes
Mechanical Tooth Brushing (Quality of Evidence: III = Low)
Clinical Efficacy
Meta-Analysis of Effect of Mechanical Tooth Brushing on VAP Rate (Crit Care Med, 2013) [MEDLINE]
Mechanical Tooth Brushing Did Not Impact VAP Risk, Duration of Mechanical Ventilation, ICU Length of Stay, or Mortality Rate
Recommendations: may decrease VAP rate, but data are unclear
Mucus Shaver (Not Addressed in Guidelines)
Mechanism: mechanical removal of biofilm from within the endotracheal tube
Clinical Efficacy: while beneficial in small trials (n = 24) (Crit Care Med, 2012) [MEDLINE], further research is required
Probiotics (Quality of Evidence: II = Moderate) (see Probiotics)
Clinical Efficacy
Systematic Review of Probiotics in Critically Ill Patients (Crit Care Med, 2012)* [MEDLINE]
Probiotics Decreased Infectious Complications: including ventilator-associated pneumonia (VAP)
Probiotics Demonstrated a Trend Toward a Decreased ICU Mortality Rate, But Did Not Impact the Hospital Mortality rate
Probiotics Did Not Impact ICU/Hospital Length of Stay
Systematic Review and Meta-Analysis of the Effect of Probiotics in VAP Prevention (Chest, 2012) [MEDLINE]
Probiotics Did Not Impact the VAP Rate: however, there was significant heterogeneity between the studies -> further investigation is required
Systematic Review and Meta-Analysis of the Effect of Probiotics on Nosocomial Pneumonia in Critically Ill Patients (Crit Care, 2012) [MEDLINE]
Probiotics Decreased the Rate of Nosocomial Pneumonia in Critically Ill Patients: howeve, further trials are required to examine mortality and other endpoints
Meta-Analysis of Probiotics in Critically Ill Patients (Chest, 2013) [MEDLINE]
Probiotics Decreased ICU-Acquired Pneumonia Rates
Probiotics Decreased ICU Length of Stay
Probiotics Did Not Impact ICU/Hospital Mortality Rates
Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
Data are Conflicting, But Probiotics May Lower VAP Rate
Probiotics Should Be Used Cautiously in Immunosuppressed Patients (Due to Case Reports of Fungemia, Bacteremia, and Aerosol Transmission of Probiotics Within the the ICU)
Use of Ultrathin Polyurethane Endotracheal Tube Cuffs (Quality of Evidence: III = Low)
Rationale: ultrathin polyurethane cuffs seal more uniformly against the tracheal wall and may prevent secretions from seeping around the cuff and into the lungs
Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
Ultrathin Polyurethane Endotracheal Tube Cuffs May Lower VAP Rate, But Data Quality is Poor
Measures Which are Generally Not Recommended (Do Not Decrease Ventilator-Associated Pneumonia Rates)
Antibiotic Prophylaxis at Time of Intubation (Not Addressed in Guidelines)
Clinical Efficacy
Study of Strategy of Using a Single Dose of Antibiotics at the Time of Intubation of Comatose Patients (Glasgow Coma Score ≤8) (Chest, 2013) [MEDLINE]: single dose of antibiotics (within 4 hrs of intubation) in comatose patients decreases the risk of early-onset VAP with no impact on mortality rate -> however, findings need to be confirmed in randomized trials
Randomized Trial of Daily Chlorhexidine Bathing to Prevent Healthcare-Associated Infections ( JAMA, 2015) [MEDLINE]
Daily Chlorhexidine Gluconate Bathing Did Not Decrease the Incidence of Healthcare-Associated Infections (Central Line-Associated Bloodstream Infections, Catheter-Related Urinary Tract Infection, Ventilator-Associated Pneumonia, or Clostridium Difficile)
Early Parenteral Nutrition (Quality of Evidence: II = Moderate)
Clinical Efficacy
EPaNIC Trial of Early Total Parenteral Nutrition (within 48 hrs) in the ICU (NEJM, 2011) [MEDLINE]
Early Total Parenteral Nutrition (within 48 hrs) Increased Risk of Nosocomial Infection and Mortality Rate, as Compared ot Initiating Total Parenteral Nutrition After 8 Days
Early Tracheostomy (Quality of Evidence: I = High) (see Tracheostomy)
Clinical Efficacy
Study of Impact of Early Tracheostomy on VAP Rate (BMJ, 2005) [MEDLINE]
Early Tracheostomy Decreases the Duration of Mechanical Ventilation and ICU Stay, But Does Not Impact Mortality or VAP Rate
Systematic Review and Meta-Analysis of Effect of Early Tracheostomy on VAP Rates (Chest, 2011) [MEDLINE]
Early Tracheostomy Did Not Impact VAP Rates, Duration of Mechanical Ventilation, or Mortality Rate
Study of Early Tracheostomy in Cardiothoracic Surgery Population (Ann Intern Med 2011) [MEDLINE]
Early Tracheostomy Did Not Decrease Length of Hospital Stay, Mortality Rate, Infectious Complication Rate, Long-Term Health-Related Quality of Life in Patients Who Required Long-Term Mechanical Ventilation After Cardiothoracic Surgery
Early Tracheostomy was Well-Tolerated and Associated with Decreased Sedation Use, Better Comfort, and Earlier Resumption of Autonomy
TracMan Trial of Early vs Late Tracheostomy in the UK (JAMA, 2013) [MEDLINE]
Early Tracheostomy (Within 4 Days of Intubation) Did Not Improve 30-Day All-Cause Mortality, 2-Year Mortality, or Length of ICU Stay
The Ability of Clinicians to Predict Which Patients Would Require Extended Mechanical Ventilation Support was Limited
Gastrointestinal/Stress Ulcer Prophylaxis (Quality of Evidence: II)
Clinical Efficacy
Systematic Review and Meta-Analysis of Stress Ulcer Prophylaxis with H2-Blockers (Crit Care Med, 2010) [MEDLINE]
H2-Blockers Decreased GI Bleeding Rate, But Only in Patient Who Were Not Receiving Enteral Nutrition
H2-Blockers Did Not Increase the Pneumonia Rate Overall, But Did Increase the Pneumonia Rate in the Subgroup Who Were Fed Enterally
H2-Blockers Did Not Impact In-Hospital Mortality Overall, But Did Increase the In-Hospital Mortality Rate in Subgroup Who Were Fed Enterally
Systematic Review and Meta-Analysis of PPI vs H2-Blockers (Crit Care Med, 2013) [MEDLINE]
PPI Were Superior to H2-Blockers in Preventing GI Bleeding
There Were No Differences in Terms of Pneumonia, Death, ICU Length of Stay
Recommendations (2012 Surviving Sepsis Guidelines; Crit Care Med, 2013) [MEDLINE]
Use Stress Ulcer Prophylaxis (H2 Blockers or Proton Pump Inhibitors) to Prevent Gastrointestinal Bleeding in Patients Who Have Bleeding Risk Factors (Grade 1B Recommendation)
When Stress Ulcer Prophylaxis is Used, Proton Pump Inhibitors are Preferred Over H2 Blockers (Grade 2D Recommendation)
Stress Ulcer Prophylaxis Should Not Be Used in Patients without Risk factors (Grade 2 B Recommendation)
Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
Stress Ulcer Prophylaxis is Generally Not Recommended as a Measure to Decrease the VAP Rate (Although May Be Used for Stress Ulcer Prophylaxis)
Kinetic Beds (Quality of Evidence: II = Moderate
Continuous Lateral Rotational Therapy and Oscillation Therapy
Clinical Efficacy
Systematic Review and Meta-Analysis of Effect of Kinetic Beds on VAP Rates (Crit Care, 2006) [MEDLINE]
Kinetic Beds Decreased VAP Rates, But Had No Impact on Duration of Mechanical Ventilation or Mortality Rate: however, there are concerns with regard to data quality from the included trials
Single-Center Austrian Prospective, Randomized Trial of the Efficacy of Continuous Lateral Rotational Therapy in VAP Prevention (Crit Care Med. 2010 Feb;38(2):486-90. doi: 10.1097/CCM.0b013e3181bc8218 [MEDLINE]
Ventilator-Associated Pneumonia Prevalence was Significantly Decreased by Continuous Lateral Rotation Therapy
Continuous Lateral Rotation Therapy Led to Decreased Duration of Ventilation and Decreased Length of Stay
Systematic Review and Meta-Analysis of Continuous Lateral Rotational Therapy in Trauma Patients (J Trauma Acute Care Surg, 2017) [MEDLINE]
Analogous to Studies Evaluating Continuous Lateral Rotation Therapy in Medical/Mixed Populations of Patients, Continuous Lateral Rotation Therapy Decreased Nosocomial Pneumonia Rates in Trauma Patients
However, There was No Impact on Mortality Rate
Data Studied was Limited, Suggesting that an Adequately Powered, Well-Designed Multi-Center Randomized Controlled Trial is Required
Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
Kinetic Beds May Decrease VAP Rate, But are Generally Not Recommended for This Indication
Monitoring of Gastric Residual Volumes (Quality of Evidence: II = Moderate)
Clinical Efficacy
Randomized Trial of Effect of Not Monitoring Gastric Residual Volume on VAP Rates in Patients Receiving Enteral Nutrition (JAMA, 2013) [MEDLINE]
Not Monitoring Gastric Residual Volumes Had No Impact on VAP Rates in Patients on Mechanical Ventilation Receiving Enteral Nutrition
Prone Positioning (Quality of Evidence: II = Moderate)
Clinical Efficacy
Most Meta-Analyses Suggest a Borderline Effect on VAP Rates and No Impact on Objective Outcomes
Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
Prone Positioning is Generally Not Recommended as a Measure to Decrease VAP Rate (although may be indicated for the management of ARDS)
Silver-Coated Endotracheal Tubes (Quality of Evidence: II = Moderate)
Mechanism: prevention of biofilm formation inside endotracheal tube
Clinical Efficacy
Beneficial in decreasing VAP rates
Cost: silver-coated endotracheal tube costs approximately $90 (vs $1-2 for standard endotracheal tube)
Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
Silver-Coated Endotracheal Tubes May Lower VAP Rate, But Do Not Impact Mortality Rate, Duration of Mechanical Ventilation, or Length of Stay
Measure Which are Neither Recommended, Nor Discouraged (Unclear Impact on Ventilator-Associated Pneumonia Rates)
Closed/In-Line Endotracheal Suctioning Systems (Quality of Evidence: II = Moderate)
Clinical Efficacy
Meta-Analysis of the Effect of Closed Endotracheal Suction Systems on VAP Rate (Br J Anaesth, 2008) [MEDLINE]
Closed Endotracheal Suction Systems Did Not Impact VAP Rate, Mortality, or ICU Length of Stay
Closed Endotracheal Suction Systems Increased the Duration of Mechanical Ventilation
Trials Conflict as to the Impact of Closed Endotracheal Suctioning Systems on Cost
Use of PEEP in Non-Hypoxemic Mechanically-Ventilated Patients Has Been Demonstrated to Decrease the Risk of VAP (Crit Care Med, 2008) [MEDLINE]
Treatment-General
Risk Factors for Multidrug-Resistant Pathogens in Hospital-Acquired Pneumonia (HAP) and Ventilator-Associated Pneumonia (VAP) (Clin Infect Dis, 2016) [MEDLINE]
Treatment of Hospital Acquired Pneumonia (HAP)
General Comments
Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
All Hospitals Should Regularly Generate and Distribute an Antibiogram (Particularly One Which is Specific for Hospital Population)
Antibiotic Treatment Based on Empiric Coverage vs Based on Microbiologic Studies
Recommendations *Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
Patients with HAP Should Be Treated Based on Results of Non-Invasively Obtained Microbiologic Studies, Rather than Being Treated Empirically (Weak Recommendation, Very Low Quality Evidence)
Non-Invasive Sampling Methods
Sputum Expectoration
Sputum Induction
Nasotracheal Suctioning
Empiric Antibiotics for Hospital-Acquired Pneumonia (HAP) (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
General Comments
Choose One Agent with Activity Against Either Methicillin-Sensitive Staphylococcus Aureus (MSSA) or Methicillin-Resistant Staphylococcus Aureus (MRSA) + One/Two Agent with Activity Against Pseudomonas Aeruginosa (and Other Gram-Negatives) (Strong Recommendation, Very Low-Quality Evidence)
If MRSA Coverage is Not Required, One the Following Agents is Suggested for Empiric MSSA Coverage (Weak Recommendation, Very Low-Quality Evidence): although nafcillin/oxacillin/cefazolin are recommended for proven MSSA, they are not required for empiric HAP coverage if one of the following agents are used (Weak Recommendation, Very Low-Quality Evidence)
Indications for MRSA Coverage in Empiric HAP Therapy (Weak Recommendation, Very Low-Quality Evidence)
High Risk for Mortality
Need for Ventilatory Support (Due to the HAP)
Septic Shock
Presence of Local Staphylococcus Aureus Methicillin-Resistance Rate >20% (or Where Resistance Rate is Unknown)
Prior Intravenous Antibiotic Use in the Last 90 Days
Empiric HAP Coverage Should Include Coverage of Pseudomonas Aeruginosa and Other Gram-Negatives (Strong Recommendation, Very Low-Quality Evidence)
Indications for Double-Coverage of Pseudomonas Aeruginosa in Empiric HAP Therapy (Weak Recommendation, Very Low-Quality Evidence)
High Risk for Mortality
Need for Ventilatory Support (Due to the HAP)
Septic Shock
Intravenous Antibiotics in the Last 90 Days
In Empiric Treatment of HAP, Avoid Using Aminoglycosides as the Sole Anti-Pseudomonal Agent (Strong Recommendation, Very Low-Quality Evidence): due to their poor lung penetration, risk of nephrotoxicity, risk of ototoxicity, and poorer clinical response rates (but no difference in mortality rate) as compared to other agents in the treatment of VAP (recommendations are based on extrapolation from the VAP data)
Dosing of Antibiotics in HAP/VAP Should Be Determined Using Pharmacokinetic/Pharmacodynamic Data (Using Blood Antibiotic Concentrations, Extended and Continuous Infusions, Weight-Based Dosing for Certain Antibiotics, etc) Rather than the Manufacturer’s Prescribing Recommendations (Weak Recommendation, Very Low-Quality Evidence)
Absence of Factors Imparting High Risk for Mortality (Need for Ventilatory Support, Septic Shock) and Absence of Factors Increasing the Likelihood of Methicillin-Resistant Staphylococcus Aureus (MRSA) (Local MRSA Rate >20% or Rate Unknown, Intravenous Antibiotics in Last 90 Days)
General Comments
Factors Imparting High-Risk for Mortality: absence of need for ventilatory support due to pneumonia and septic shock
Factors Increasing the Likelihood of Methicillin-Resistant Staphylococcus Aureus (MRSA)
Presence of Local Staphylococcus Aureus Methicillin-Resistance Rate >20% (or Where Resistance Rate is Unknown)
Prior Intravenous Antibiotic Use in the Last 90 Days
Levofloxacin (Levaquin) (see Levofloxacin): 750 mg IV q24hrs
Absence of Factors Imparting High Risk for Mortality (Need for Ventilatory Support, Septic Shock), But Presence of Factors Increasing the Likelihood of Methicillin-Resistant Staphylococcus Aureus (MRSA) (Local MRSA Rate >20% or Rate Unknown, Intravenous Antibiotics in Last 90 Days)
One of the Following (Strong Recommendation, Moderate-Quality Evidence)
Oxazolidinones
Linezolid (Zyvox) (see Linezolid): 600 mg IV q12hrs
Glycopeptides
Vancomycin (see Vancomycin): consider load of 25-30 mg/kg IV for severe illness, then 15 mg/kg IV q8-12 hrs with target trough 15-20 mg/mL
Pathogen-Specific Antibiotics for Hospital-Acquired Pneumonia (HAP) (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
HAP/VAP Due to Methicillin-Resistant Staphylococcus Aureus (MRSA) (see Staphylococcus Aureus)
Recommended Agents for the Treatment of HAP/VAP Due to MRSA (Strong Recommendation, Moderate-Quality Evidence): meta-analyses indicate no difference in mortality between these agents (Clin Infect Dis, 2016) [MEDLINE]
Oxazolidinones
Linezolid (Zyvox) (see Linezolid): 600 mg IV q12hrs
Glycopeptides
Vancomycin (see Vancomycin): consider load of 25-30 mg/kg IV, then 15 mg/kg IV q8-12 hrs with target trough 15-20 mg/mL
Antibiotics for HAP/VAP Due to Pseudomonas Aeruginosa Should Be Guided by Antimicrobial Susceptibility Testing (Strong Recommendation, Low-Quality Evidence)
Aminoglycoside Monotherapy for HAP/VAP Due to Pseudomonas Aeruginosa is Not Recommended (Strong Recommendation, Very Low-Quality Evidence)
Indications for Double-Coverage of Pseudomonas Aeruginosa HAP/VAP (Strong Recommendation, Low-Quality Evidence)
High Risk for Mortality: defined as mortality risk >25% (low risk for mortality is defined as <15% risk)
Need for Ventilatory Support
Septic Shock
Lack of Availability of Antibiotic Susceptibility Testing
HAP/VAP Due to Extended-Spectrum β-Lactamase (ESBL)-Producing Gram-Negative Bacilli
Antibiotics for HAP/VAP Due to ESBL-Producing Gram-Negative Bacilli Should Be Guided by Antimicrobial Susceptibility Testing (Strong Recommendation, Very Low-Quality Evidence)
HAP/VAP Due to Acinetobacter Should Be Treated with Ampicillin-Sulbactam (Unasyn) or a Carbapenem, if Susceptible (Weak Recommendation, Low-Quality Evidence)
For HAP/VAP Due to Acinetobacter, Tigecycline is Not Recommended (Strong Recommendation, Low-Quality Evidence)
For HAP/VAP Due to Acinetobacter Which is Susceptible Only to Polymyxins, Intravenous Polymyxin Should Be Used (Strong Recommendation, Low-Quality Evidence) with Inhaled Colistin (Weak Recommendation, Low-Quality Evidence)
For HAP/VAP Due to Acinetobacter Which is Susceptible Only to Colistin, Adjunctive Rifampicin is Not Recommended (Weak Recommendation, Moderate-Quality Evidence)
HAP/VAP Due to Carbapenem-Resistant Pathogens
For HAP/VAP Due to Carbapenem-Resistant Pathogens Which is Only Sensitive to Polymyxins, Intravenous Polymyxin Should Be Used (Strong Recommendation, Moderate-Duality Evidence) with Inhaled Colistin (Weak)
Duration of Therapy for Hospital-Acquired Pneumonia (HAP)
Clinical Efficacy
Cochrane Database Systematic Review and Meta-Analysis of Using Serum Procalcitonin to Start or Stop Antibiotics in Acute Respiratory Tract Infection (Cochrane Database Syst Rev, 2017) [MEDLINE]
Use of Serum Procalcitonin to Guide Initiation and Duration of Antibiotics Results in Lower Risks of Mortality, Lower Antibiotic Consumption, and Lower Risk of Antibiotic-Associated Adverse Effects
Results were Similar for Different Clinical Settings and Types of Acute Respiratory Tract Infections
Future Research is Required to Confirm the Results in Immunocompromised Patients and Patients with Non-Respiratory Infections
Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
For HAP/VAP, Antibiotic Therapy Should Be De-Escalated (Weak Recommendation, Very Low-Quality Evidence)
For Patients with HAP, a 7 Day Course of Therapy is Recommended Over Longer Duration of Therapy (Strong Recommendation, Very Low-Quality Evidence): some clinical situations may merit a shorter/longer duration of therapy, depending on the rate of improvement in clinical/radiologic/laboratory parameters
For HAP/VAP, Combined Clinical Criteria and Serum Procalcitonin Should Be Used to Guide Antibiotic Discontinuation Over Clinical Criteria Alone (Weak Recommendation, Low-Quality Evidence)
However, is it Unclear if there are Benefits of Using Serum Procalcitonin to Determine Whether or Not to Discontinue Antibiotic Therapy in Settings Where Standard Antimicrobial Therapy for VAP is Already ≤7 Days
For HAP/VAP, Clinical Pulmonary Infection Score (CPIS) Should Not Be Used to Guide Antibiotic Discontinuation (Weak Recommendation, Low-Quality Evidence)
Treatment of Ventilator-Associated Tracheobronchitis
Clinical Efficacy
Antibiotic Therapy May Shorten the Duration of Mechanical Ventilation, But it is Unclear as to Whether it Improves Other Clinical Outcomes (Due to Inconsistent Data)
Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
Patients with Ventilator-Associated Tracheobronchitis Should Not Be Treated with Antibiotic Therapy (Weak Recommendation, Low-Quality Evidence)
Treatment of Ventilator-Associated Pneumonia (VAP)
General Comments
Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
All Hospitals Should Regularly Generate and Distribute an Antibiogram (Particularly One Which is Specific for the Intensive Care Unit Population)
Microbial Flora and Resistance Patterns Vary Significantly Between Countries, Regions, and Hospitals
Antibiogram Should Inform Empiric Treatment Decisions
Meta-Analyses Indicate that Inadequate and/or Delayed Antibiotic Treatment of VAP Results in a (2.34x) Increased Mortality Rate (J Crit Care, 2008) [MEDLINE]
Initial Antibiotic Choice Based on Gram Stain (see Sputum Culture)
Clinical Efficacy-Use of Gram Stain to Guide Initial Antibiotic Therapy in Ventilator-Associated Pneumonia
Japanese GRACE-VAP Multicenter, Open-Label, Noninferiority Randomized Trial of the Use of Gram Stain to Guide the Initial Antibiotic Treatment of Ventilator-Associated Pneumonia (JAMA Netw Open, 2022) [MEDLINE]: n = 206 (Patients Age ≥15 from 12 ICU’s)
Clinical Response Occurred in 76.7% of Patients in the Gram Stain-Guided Group and 71.8% of Patients in the Guideline-Based Group (Risk Difference, 0.05; 95% CI: -0.07 to 0.17; P < 0.001 for Noninferiority)
Reduced Use of Antipseudomonal Agents (30.1%; 95% CI: 21.5%-39.9%; P < .001) and Anti-MRSA Agents (38.8%; 95% CI: 29.4%-48.9%; P < 0.001) was Observed in the Gram Stain-Guided Group vs Guideline-Based Group
The 28-Day Cumulative Incidence of Mortality was 13.6% (n = 14) in the Gram Stain-Guided Group vs 17.5% (n = 18) in the Guideline-Based Group (P = 0.39)
Escalation of Antibiotics According to Culture Results was Performed in 6.8% of Patients in the Gram Stain-Guided Group and 1.0% of Patients in the Guideline-Based Group (P = 0.03)
There were No Significant Differences Between the Groups in ICU-Free Days, Ventilator-Free Days, and Adverse Events
Authors Concluded that Gram Stain-Guided Antibiotic Treatment was Non inferior to Guideline-Based Antibiotic Treatment and Significantly Decreased the Use of Broad-Spectrum Antibiotics in Ventilator-Associated Pneumonia
Antibiotic Use Based on Quantitative Cultures in Ventilator-Associated Pneumonia (VAP)
Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
Non-Invasive Sampling with Semiquantitative Cultures is Recommended Over Non-Invasive Sampling with Quantitative Cultures or Invasive Sampling with Quantitative Cultures (Weak Recommendation, Low Quality Evidence): there is no evidence that invasive microbiologic sampling improves clinical outcomes compared with non-invasive sampling with either quantitative or semiquantitative cultures
Quantitative Threshold for Endotracheal Tube Aspirate: <10 to the 5th CFU/mL
Invasive Sampling Methods: bronchoscopy with bronchoalveolar lavage or protected brush specimen, blind bronchial sampling (“mini-BAL”)
Effect of Invasive Sampling with Quantitative Cultures on Antibiotic Exposure is Unclear
If Invasive Sampling with Quantitative Cultures are Performed, Diagnostic Thresholds for VAP (Protected Brush Specimen with <10 to the 3rd CFU/mL, Bronchoalveolar With <10 to the 4th CFU/mL) Should Be Utilized to Decide Whether to Stop Antibiotics (Weak Recommendation, Very Low Quality Evidence)
Empiric Antibiotics for Ventilator-Associated Pneumonia (VAP)
Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
General Comments
Choose One Agent with Activity Against Either Methicillin-Sensitive Staphylococcus Aureus (MSSA) or Methicillin-Resistant Staphylococcus Aureus (MRSA) + One β-Lactam Agent with Activity Against Pseudomonas Aeruginosa (and Gram-Negatives) + One Non-β-Lactam Agent with Activity Against Pseudomonas Aeruginosa (and Other Gram-Negatives) (Strong Recommendation, Low-Quality Evidence)
Use an Agent Active Against Methicillin-Resistant Staphylococcus Aureus (MRSA) for the Following Indications (Weak Recommendation, Very Low-Quality Evidence)
Presence of Local Staphylococcus Aureus Methicillin-Resistance Rate >10-20% (or Where Resistance Rate is Unknown)
Prior Intravenous Antibiotic Use in the Last 90 Days
Use Agents from Two Different Anti-Pseudomonal Classes for the Following Indications (Weak Recommendation, Low-Quality Evidence): the rationale for double-covering Pseudomonas is to increase the probability that the organism will be sensitive to at least one of the agents
Presence of Local Gram-Negative Resistance Rate >10% for the Agent Being Considered for Monotherapy (or Where Resistance Rate is Unknown)
Presence of Structural Lung Diseases Which Increase the Risk of Gram-Negative Pneumonia (Bronchiectasis, Cystic Fibrosis)
Prior Intravenous Antibiotic Use in the Last 90 Days
In Patients with Suspected VAP, Avoid Aminoglycosides if Alternative Agents with Gram-Negative Coverage are Available (Weak Recommendation, Low-Quality Evidence): due to their poor lung penetration, risk of nephrotoxicity, risk of ototoxicity, and poorer clinical response rates (but no difference in mortality rate) than that of other drug classes
In Patients with Suspected VAP, Avoid Colistin if Alternative Agents with Gram-Negative Coverage are Available (Weak Recommendation, Very Low-Quality Evidence)
Dosing of Antibiotics in HAP/VAP Should Be Determined Using Pharmacokinetic/Pharmacodynamic Data (Using Blood Antibiotic Concentrations, Extended and Continuous Infusions, Weight-Based Dosing for Certain Antibiotics, etc) Rather than the Manufacturer’s Prescribing Recommendations (Weak Recommendation, Very Low-Quality Evidence)
Agents with Activity Against Methicillin-Sensitive Staphylococcus Aureus (MSSA) (see Staphylococcus Aureus)
Preferred Agents for Proven MSSA: due to decreased likelihood of inducing resistance
Agents with Activity Against Methicillin-Resistant Staphylococcus Aureus (MRSA) (see Staphylococcus Aureus) (Strong Recommendation, Moderate-Quality Evidence)
Ciprofloxacin (Cipro) (see Ciprofloxacin): 400 mg IV q8hrs
Levofloxacin (Levaquin) (see Levofloxacin): 750 Hg IV q24hrs
Aminoglycosides (see Aminoglycosides): in meta-analyses, aminoglycoside regimens are associated with lower clinical response rates, but no difference in mortality rate
General Comments: aminoglycosides should be avoided if alternative agents with adequate Gram-negative coverage are available (Weak Recommendation, Low-Quality Evidence)
Colistin (see Colistin): load 5 mg/kg IV, then 2.5 mg x (1.5 x CrCl + 30) IV q12hrs
In Cases with Resistant Pseudomonas Aeruginosa, Combination Intravenous + Aerosolized Colistin was Superior to Intravenous Colistin Alone, in Terms of Cure Rate and Days of Mechanical Ventilation After VAP Onset (Chest, 2013) [MEDLINE]
Polymyxin B (see Polymyxin B): 2.5–3.0 mg/kg/day IV divided in 2 daily doses
Pathogen-Specific Antibiotics for Ventilator-Associated Pneumonia (VAP) (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
Role of Inhaled Antibiotic Therapy in the Management of Multidrug-Resistant Gram-Negative Bacilli
Gram-Negative Bacilli Susceptible Only to Aminoglycosides/Polymyxins Should Be Treated with Both Inhaled (Gentamicin, Tobramycin, Colistin) and Systemic Antibiotics, as Opposed to Systemic Antibiotics Alone (Weak Recommendation, Very Low-Quality Evidence): meta-analyses suggest that the addition of inhaled antibiotics to systemic antibiotics increased the clinical cure rate, but had no effect on the mortality rate or nephrotoxicity (Clin Infect Dis, 2016) [MEDLINE]
Rationale: antibiotic efficacy against bacteria which reside within purulent secretions may require antibiotic concentrations which are >10–25x the minimum inhibitory concentration (MIC) (these MIC’s cannot be achieved with intravenous therapy alone and the addition of inhaled antibiotic therapy may be beneficial in achieving the relevant MIC)
Notably, subtherapeutic antibiotic concentrations within the lung and airway may further select antibiotic-resistant organisms
It is Also Reasonable to Consider the Addition of Inhaled Antibiotics as Adjunctive Therapy in Patients Who are Not Responding to Intravenous Antibiotics Alone (Regardless of Whether the Infecting Organism is Multidrug-Resistant or Not)
HAP/VAP Due to Methicillin-Resistant Staphylococcus Aureus (MRSA) (see Staphylococcus Aureus)
Recommended Agents for the Treatment of HAP/VAP Due to MRSA (Strong Recommendation, Moderate-Quality Evidence): meta-analyses indicate no difference in mortality between these agents (Clin Infect Dis, 2016) [MEDLINE]
Oxazolidinones
Linezolid (Zyvox) (see Linezolid): 600 mg IV q12hrs
Glycopeptides
Vancomycin (see Vancomycin): consider load of 25-30 mg/kg IV, then 15 mg/kg IV q8-12 hrs with target trough 15-20 mg/mL
Antibiotics for HAP/VAP Due to Pseudomonas Aeruginosa Should Be Guided by Antimicrobial Susceptibility Testing (Strong Recommendation, Low-Quality Evidence)
Aminoglycoside Monotherapy for HAP/VAP Due to Pseudomonas Aeruginosa is Not Recommended (Strong Recommendation, Very Low-Quality Evidence)
Indications for Double-Coverage of Pseudomonas Aeruginosa HAP/VAP (Strong Recommendation, Low-Quality Evidence)
High Risk for Mortality: defined as mortality risk >25% (low risk for mortality is defined as <15% risk)
Lack of Availability of Antibiotic Susceptibility Testing
HAP/VAP Due to Extended-Spectrum β-Lactamase (ESBL)-Producing Gram-Negative Bacilli
Antibiotics for HAP/VAP Due to ESBL-Producing Gram-Negative Bacilli Should Be Guided by Antimicrobial Susceptibility Testing (Strong Recommendation, Very Low-Quality Evidence)
HAP/VAP Due to Acinetobacter Should Be Treated with Ampicillin-Sulbactam (Unasyn) or a Carbapenem, if Susceptible (Weak Recommendation, Low-Quality Evidence)
For HAP/VAP Due to Acinetobacter, Tigecycline is Not Recommended (Strong Recommendation, Low-Quality Evidence)
For HAP/VAP Due to Acinetobacter Which is Susceptible Only to Polymyxins, Intravenous Polymyxin Should Be Used (Strong Recommendation, Low-Quality Evidence) with Inhaled Colistin (Weak Recommendation, Low-Quality Evidence)
For HAP/VAP Due to Acinetobacter Which is Susceptible Only to Colistin, Adjunctive Rifampicin is Not Recommended (Weak Recommendation, Moderate-Quality Evidence)
HAP/VAP Due to Carbapenem-Resistant Pathogens
For HAP/VAP Due to Carbapenem-Resistant Pathogens Which is Only Sensitive to Polymyxins, Intravenous Polymyxin Should Be Used (Strong Recommendation, Moderate-Duality Evidence) with Inhaled Colistin (Weak)
Antibiotic Choice and Stewardship in Ventilator-Associated Pneumonia (VAP)
Goals of Antibiotic Stewardship
Optimization of Clinical VAP Outcomes
Minimization of Antibiotic Resistance, Antibiotic Toxicity, Adverse Events, and Selection of Pathogenic Organisms
Decrease in Health Care Costs
Techniques of Antibiotic Stewardship
Formulary Restriction/Preauthorization for Antibiotics
Audit of Antibiotic Use with Feedback to the Prescriber
De-Escalation of Antibiotics
Start with Broad-Spectrum Antibiotic Strategy
At First Opportunity (with the Aid of Culture Data), Provider Should Decrease the Number of Antimicrobial Agents, Shorten the Duration of Antimicrobial Agent Exposure, and/or Discontinue Antimicrobial Therapy (as Dictated by the Patient’s Clinical Response and Culture Results)
Clinical Efficacy
Study of Microbial Isolates and Susceptibility Across Hospital Sites in Different Spanish Cities (Am J Respir Crit Care Med, 1999) [MEDLINE]
Etiologies of VAP Varied Across the Treatment Sites
Therefore, Authors Conclude that Antimicrobial Prescribing Practices Should Be Based on Information About Patterns of Multi-Drug Resistant Isolates from Each Institution, Instead of Following General Recommendations
PneumA Trial of Shortened Antibiotic Duration in VAP Treatment (JAMA, 2003) [MEDLINE]
Among Patients Who Had Received Initial Empiric Antibiotic Therapy (with the Possible Exception of Those with Non-Fermenting GNR Infections), 8-day Regimen was Comparable to 15-Day Regimen in Terms of Clinical Outcome: 8-day group had less antibiotic use
Trial Using Antibiotic De-Escalation in VAP (Crit Care Med, 2004) [MEDLINE]
De-Escalation was Possible in 31.4% of Cases
Bronchoscopic and/or tracheal aspirate cultures were instrumental in allowing de-escalation
Authors did not perform de-escalation without a known pathogen
De-Escalation was Performed in Only 2.7% of Cases with Non-Fermenting GNR’s and Other Potentially Multi-Drug Resistant Organisms (Such as Pseudomonas Aeruginosa)
Multicenter Observational Study of VAP (Chest, 2006) [MEDLINE]
De-Escalation was Performed in 22.1% of Cases (and Escalation in 15.3% of Cases)
De-Escalation was Performed in Only 6.5% of Cases without a Known Pathogen
Mortality was Significantly Decreased in Cases with De-Escalation (17%), vs 23.7% in Those with No Change in Therapy and 42.6% in Those with Escalation in Therapy
Study of the Impact of Regular Communication Between Infectious Disease and Critical Care Providers on Antimicrobial Use and Patient Outcome (Crit Care Med, 2013) [MEDLINE]
Active Communication Between Critical Care Providers and Infectious Disease Providers Significantly Decreases Medical ICU Antibiotic Overuse (by Earlier Modification or Cessation of Antibiotics) without an Increase in Mortality: this may decrease health care costs
Systematic Review of Antibiotic De-Escalation in the ICU (Clin Infect Dis, 2016) [MEDLINE]
There is No Uniform Definition of “De-Escalation”
There is Little Evidence Related to the Effect of De-Escalation on Duration of Antimicrobial Therapy, Emergence of Resistance, or Costs
There was an Association Between De-Escalation and Improved Outcome: however, from the evidence, it is not clear that this is causal (since patients with clinical improvement may have been the ones with higher rates of de-escalation)
Recommendations
Knowledge of Local Antibiograms is Essential in Determining Appropriate Initial Antibiotic Regimens
Antibiotic De-Escalation (to a Narrower Regimen) is Recommended, Whenever Possible (Weak Recommendation, Very Low-Quality Evidence) (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
Collaborative Approach Between Critical Care and Infectious Disease Providers is Recommended to Decrease Antibiotic Overuse
Duration of Antibiotic Therapy in Ventilator-Associated Pneumonia (VAP)
Clinical Efficacy
Cochrane Database Systematic Review and Meta-Analysis of Using Serum Procalcitonin to Start or Stop Antibiotics in Acute Respiratory Tract Infection (Cochrane Database Syst Rev, 2017) [MEDLINE]
Use of Serum Procalcitonin to Guide Initiation and Duration of Antibiotics Results in Lower Risks of Mortality, Lower Antibiotic Consumption, and Lower Risk of Antibiotic-Associated Adverse Effects
Results were Similar for Different Clinical Settings and Types of Acute Respiratory Tract Infections
Future Research is Required to Confirm the Results in Immunocompromised Patients and Patients with Non-Respiratory Infections
Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
For HAP/VAP, Antibiotic Therapy Should Be De-Escalated (Weak Recommendation, Very Low-Quality Evidence)
For VAP, a 7 Day Course of Therapy is Recommended Over Longer Duration of Therapy (Strong Recommendation, Moderate-Quality Evidence): some clinical situations may merit a shorter/longer duration of therapy, depending on the rate of improvement in clinical/radiologic/laboratory parameters
Evidence Indicates that Shorter Courses of Antibiotics Decrease Antibiotic Exposure and the Risk of Recurrent Pneumonia Due to Multidrug-Resistant Organisms
Duration of Antibiotic Therapy Do Not Appear to Impact the Mortality Rate
For HAP/VAP, Combined Clinical Criteria and Serum Procalcitonin Should Be Used to Guide Antibiotic Discontinuation Over Clinical Criteria Alone (Weak Recommendation, Low-Quality Evidence)
However, is it Unclear if there are Benefits of Using Serum Procalcitonin to Determine Whether or Not to Discontinue Antibiotic Therapy in Settings Where Standard Antimicrobial Therapy for VAP is Already ≤7 Days
For HAP/VAP, Clinical Pulmonary Infection Score (CPIS) Should Not Be Used to Guide Antibiotic Discontinuation (Weak Recommendation, Low-Quality Evidence)
Oxygen Should Be Prescribed to Achieve a Target Saturation of 94–98% for Most Acutely Ill Patients or 88–92% or Patient-Specific Target Range for Those at Risk of Hypercapnic Respiratory Failure
Best Practice is to Prescribe a Target Range for All Hospitalized Patients at the Time of Hospital Admission So that Appropriate Oxygen Therapy Can Be Started in the Event of Unexpected Clinical Deterioration with Hypoxemia and Also to Ensure that the Oximetry Section of the Early Warning Score Can Be Scored Appropriately
Recommendations (British Medical Journal-Oxygen Therapy for Acutely Ill Medical Patients: Clinical Practice Guideline, 2018) (BMJ, 2018) [MEDLINE]
Supplemental Oxygen Therapy Should Be Titrated to SpO2 ≤96% (Strong Recommendation)
SpO2 >96% likely is Associated with a Small, But Important, Increased Risk of Death without Plausible Clinical Benefit
Prognostic Factors
Hospital-Acquired Pneumonia (HAP)
Effect of Hospital-Acquired Pneumonia (HAP) on Mortality Rate
Mortality Rate of HAP in the ICU Approaches that of VAP (Chest, 2005) [MEDLINE]; (Crit Care Med, 2013) [MEDLINE]
Ventilator-Associated Pneumonia (VAP)
Effect of Ventilator-Associated Pneumonia (VAP) on Mortality Rate
Mortality Rate Attributable to VAP is 13% (Lancet Infect Dis, 2013) [MEDLINE]: however, the all-cause mortality rate associated with VAP has been estimated to be 20-50%
Effect of Ventilator-Associated Pneumonia (VAP) on Other Outcomes
VAP Increased the Duration of Mechanical Ventilation (Clin Infect Dis, 2010) [MEDLINE]; (Infect Control Hosp Epidemiol, 2012) [MEDLINE]: by 7.6-11.5 days
VAP Increased Hospital Length of Stay (Clin Infect Dis, 2010) [MEDLINE]; (Infect Control Hosp Epidemiol, 2012) [MEDLINE]: by 11.5-13.1 days
Excess Cost Associated with VAP is Estimated to $40k Per Patient (Infect Control Hosp Epidemiol, 2012) [MEDLINE]
Ventilator-Associated Pneumonia (VAP) in the Elderly (Crit Care Med, 2014) [MEDLINE]
Advanced Age
Advanced Age Did Not Increase the Prevalence of VAP, But it Increased the VAP-Associated Mortality Rate (Age 65-74 y/o and Age >75 y/o Had 51% Mortality Rate, as Compared to 35% Mortality Rate for Younger Age Groups)
Older Age Groups Had Higher Incidence of Chronic Congestive Heart Failure, Diabetes Mellitus, and Non-Metastatic Cancer
Age Did Not Impact the Duration of Mechanical Ventilation or Length of ICU Stay
Poor Prognostic Factor: Patients who have initially been treated with inappropriate antibiotics
No difference in morbidity or mortality has been found between the patients who had VAP diagnosed with quantitative sputum c/s vs protected brush specimens
Quantitative BAL cultures has not been shown to improve VAP outcome
Unknown if there is a difference in morbidity or mortality if one diagnoses VAP with a nonquantitative sputum c/s vs quantitative culture technique
Hospital Readmission for Pneumonia
Clinical Efficacy
Study of Factors Related to Hospital Readmission for Pneumonia (Clin Infect Dis, 2013) [MEDLINE]
Hospital Readmission Rate for Pneumonia: 20%
Patients with HCAP were 7.5x More Likely to Be Readmitted than Patients with CAP
Criteria in HCAP that Associated with the Risk of Hospital Readmission
Admission from Long-term Care (adjusted odds ratio [AOR], 2.2 [95% CI, 1.4-3.4])
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Diagnosis
Ventilator-Associated Pneumonia: The Clinical Pulmonary Infection Score as a Surrogate for Diagnostics and Outcome. Clin Infect Dis. 2010 Aug 1;51 Suppl 1:S131-5. doi: 10.1086/653062 [MEDLINE]
Methicillin-resistant Staphylococcus aureus nasal colonization is a poor predictor of intensive care unit-acquired methicillin-resistant Staphylococcus aureus infec- tions requiring antibiotic treatment. Crit Care Med 2010; 38:1991–5 [MEDLINE]
Procalcitonin-guided interventions against infections to increase early appropriate antibiotics and improve survival in the intensive care unit: a randomized trial. Crit Care Med 2011; 39:2048–58 [MEDLINE]
Diagnostic accuracy of clinical pulmonary infection score for ventilator-associated pneumonia: a meta-analysis. Respir Care 2011; 56:1087–94 [MEDLINE]
Gram stain useful in the microbiologic diagnosis of VAP? A meta-analysis. Clin Infect Dis 2012; 55:551–61 [MEDLINE]
ProACT Trial. Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infection. N Engl J Med. 2018 Jul 19;379(3):236-249. doi: 10.1056/NEJMoa1802670 [MEDLINE]
Clinical
Ventilator-Associated Events (VAE)
Ventilator-Associated Pneumonia: New Definitions. Crit Care Clin. 2017 Apr;33(2):277-292. doi: 10.1016/j.ccc.2016.12.009. Epub 2017 Jan 18 [MEDLINE]
CDC Device-Associated Module for VAE Definitions (1/17) [LINK]
Prevalence and test characteristics of national health safety network ventilator-associated events. Crit Care Med 2014; 42(9):2019–28 [MEDLINE]
Ventilator-Associated Tracheobronchitis
Effect of ventilator-associated tracheobronchitis on outcome in patients without chronic respiratory failure: a case-control study. Crit Care 2005; 9:R238–45 [MEDLINE]
Prevention of Ventilator-Associated Pneumonia
Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 1999;354:1851-1858 [MEDLINE]
Guidelines for preventing health-care–associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53:1-36 [MEDLINE]
De-escalation therapy in ventilator-associated pneumonia. Crit Care Med 2004; 32:2183–2190 [MEDLINE]
Prevention of hospital-associated pneumonia and ventilator-associated pneumonia. Crit Care Med. 2004;32:1396-1405 [MEDLINE]
Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care. Cochrane Database Syst Rev. 2004;(1):CD000022 [MEDLINE]
Intrahospital transport of critically ill ventilated patients: a risk factor for ventilator-associated pneumonia–a matched cohort study. Crit Care Med, 2005: 33: 2471-2478 [MEDLINE]
Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ. 2005;330:1243 [MEDLINE]
The ventilator circuit and ventilator-associated pneumonia. Respir Care. 2005;50:774-785 [MEDLINE]
Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis. Am J Med 2005;118:11-18 [MEDLINE]
Oral care reduces incidence of ventilator-associated pneumonia in ICU populations. Intensive Care Med 2006;32:230-236 [MEDLINE]
Kinetic bed therapy to prevent nosocomial pneumonia in mechanically ventilated patients: a systematic review and meta-analysis. Crit Care 2006;10(3):R70 [MEDLINE]
Topical chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. Crit Care Med 2007;35:595-602 [MEDLINE]
Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ 2007;334:889 [MEDLINE]
Prevention measures for ventilator-associated pneumonia: a new focus on the endotracheal tube. Curr Opin Infect Dis. 2007 Apr;20(2):190-7 [MEDLINE]
Closed tracheal suction systems for prevention of ventilator-associated pneumonia. Br J Anaesth. 2008;100:299-306 [MEDLINE]
Positive-end expiratory pressure reduces incidence of ventilator-associated pneumonia in nonhypoxemic patients. Crit Care Med. 2008;36(8):2225 [MEDLINE]
Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 2009;360(1):20–31 [MEDLINE]
Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009;373:1874–1882 [MEDLINE]
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A clinical assessment of the Mucus Shaver: A device to keep the endotracheal tube free from secretions. Crit Care Med 2012;40:119-124 [MEDLINE]
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Antibiotic stewardship in hospital-acquired pneumonia. Chest. 2013;143:1195–1196. doi:10.1378/chest.12-2729 [MEDLINE]
Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013;309:2121–2129 [MEDLINE]
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Treatment
General
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PneumA Trial. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA. 2003;290(19):2588-2598 [MEDLINE]
Antimicrobial activity of tigecycline tested against organisms causing community-acquired respiratory tract infection and nosocomial pneumonia. Diagn Microbiol Infect Dis. 2005;52:187-193
Parenteral and inhaled colistin for treatment of ventilator-associated pneumonia. Clin Infect Dis. 2006;43(suppl 2):S89-S94
Clinical characteristics and treatment patterns among patients with ventilator-associated pneumonia. Chest 2006; 129:1210–1218 [MEDLINE]
Impact of inappropriate antibiotic therapy on mortality in patients with ventilator-associated pneumonia and blood stream infection: a meta-analysis. J Crit Care 2008; 23:91–100 [MEDLINE]
Antimicrobial stewardship programs: mandatory for all ICUs. Crit Care. 2012;16:179. doi:10.1186/cc11853 [MEDLINE]
Impact of regular collaboration between infectious diseases and critical care practitioners on antimicrobial utilization and patient outcome. Crit Care Med. 2013;41:2099–2107. doi: 10.1097/CCM.0b013e31828e9863 [MEDLINE]
Effect of aerosolized colistin as adjunctive treatment on the outcomes of microbiologically documented ventilator-associated pneumonia caused by colistin-only susceptible gram-negative bacteria. Chest. 2013 Dec;144(6):1768-75. doi: 10.1378/chest.13-1018 [MEDLINE]
Antibiotic stewardship in hospital-acquired pneumonia. Chest. 2013;143:1195–1196. doi:10.1378/chest.12-2729 [MEDLINE]
What can be expected from antimicrobial de-escalation in the critically ill? Intensive Care Med 2014; 40:92–5 [MEDLINE]
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Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016 Sep 1;63(5):e61-e111. doi: 10.1093/cid/ciw353. Epub 2016 Jul 14 [MEDLINE]
Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev. 2017 Oct 12;10:CD007498. doi: 10.1002/14651858.CD007498.pub3 [MEDLINE]
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Respiratory Support
British Thoracic Society Emergency Oxygen Guideline Group BTS Emergency Oxygen Guideline Development Group. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax 2017;72(Suppl 1):ii1-90. 10.1136/ thoraxjnl-2016-209729 pmid:28507176 [MEDLINE]
Oxygen therapy for acutely ill medical patients: a clinical practice guideline. BMJ. 2018 Oct 24;363:k4169. doi: 10.1136/bmj.k4169 [MEDLINE]
The timing of tracheotomy in critically ill patients undergoing mechanical ventilation: a systematic review and meta-analysis of randomized controlled trials. Chest 2011;140(6):1456–1465 [MEDLINE]
Early percutaneous tracheotomy versus prolonged intubation of mechanically ventilated patients after cardiac surgery: a randomized trial. Ann Intern Med 2011;154:373–383 [MEDLINE]
Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013;309:2121–2129 [MEDLINE]
Prognosis
Readmission following hospitalization for pneumonia: the impact of pneumonia type and its implication for hospitals. Clin Infect Dis. 2013 Aug;57(3):362-7 [MEDLINE]
Editorial commentary: “excess readmissions” for pneumonia: a dilemma with a penalty. Clin Infect Dis. 2013 Aug;57(3):368-9 [MEDLINE]
