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  • Ventilator-associated pneumonia (VAP) remains a frequent complication of mechanical ventilation (MV) that is associated with mortality in excess of that caused by the underlying disease alone, particularly in case of infection due to high-risk pathogens, such as Pseudomonas aeruginosa, and when initial antibiotic therapy is inappropriate.

  • The predominant organisms responsible for infection are Enterobacteriaceae, P. aeruginosa, and Staphylococcus aureus, but etiologic agents differ widely according to ICU patient-specific characteristics, duration of hospital stay, prior antimicrobial therapy, and local epidemiology.

  • Although appropriate antibiotics may improve survival in patients with VAP, use of empirical broad-spectrum antibiotics in patients without infection is potentially harmful, facilitating colonization and superinfection with multidrug-resistant (MDR) microorganisms. Any strategy designed to evaluate patients suspected of having developed VAP, therefore, should be able to withhold antimicrobial treatment in patients without pneumonia.

  • Because even a few doses of a new antimicrobial agent can negate results of microbiologic cultures, pulmonary secretions in patients, suspected of having developed VAP, should always be obtained before new antibiotics are administered.

  • Empirical treatment of patients with VAP should be selected based on available epidemiologic characteristics, information provided by direct examination of pulmonary secretions, intrinsic antibacterial activities of antimicrobial agents, and their pharmacokinetic characteristics.

  • Rapid diagnostic techniques using biomolecular approaches allow early pathogen identification and, to some extent, determination of antimicrobial susceptibility. These new technologies, when coupled with strong antibiotic stewardship programs, reduce the time to appropriate antimicrobial therapy in patients infected with MDR pathogens, and avoid broad-spectrum regimens when the infection can be treated with a narrow-spectrum antibiotic.

  • Altered pharmacokinetics secondary to increase in volume of distribution and/or elimination clearance in critically ill patients can result in insufficient antibiotic concentrations when standard dosages are administered, emphasizing the need to carefully monitor peak and trough levels of antibiotics when treating resistant pathogens.

  • Once the microbiologic data become available, antimicrobial therapy should be reevaluated in order to avoid prolonged use of a broader spectrum of antibiotic therapy than is justified by the available information. For many patients, including those with late-onset infection, the culture data will not show the presence of highly resistant pathogens, and in these individuals, therapy can be narrowed and reduced to a single agent in light of the susceptibility pattern of the causative pathogens without risking inappropriate treatment.

  • Duration of antimicrobial therapy can be limited to 7 days in most patients with VAP.

  • Any VAP prevention program should target improved methods of sedation, use of protocols to facilitate and accelerate weaning, mobilizing patients as soon as possible, and using noninvasive ventilation whenever possible. All are based on the application of strict protocols. Placement of ventilated patients in a semirecumbent position when enteral nutrition is used may also have an impact on the frequency of VAP.


Ventilator-associated pneumonia (VAP) is the most frequent ICU-acquired infection among patients who are treated with invasive mechanical ventilation (MV).1 In contrast to infections ...

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