RT Book, Section
A1 Chastre, Jean
A1 Fagon, Jean-Yves
A2 Hall, Jesse B.
A2 Schmidt, Gregory A.
A2 Wood, Lawrence D.H.
SR Print(0)
ID 2289085
T1 Chapter 43. Ventilator-Associated Pneumonia
T2 Principles of Critical Care, 3e
YR 2005
FD 2005
PB The McGraw-Hill Companies
PP New York, NY
SN 9780071416405
LK accessmedicine.mhmedical.com/content.aspx?aid=2289085
RD 2022/08/12
AB The  risk  of  nosocomial  pneumonia  is  considerably  higher  in  the  subset  of  ICU  patients  treated  with  mechanical  ventilation,  with  an  incremental  risk  of  about  1%  per  day  of  ventilation.Ventilator-associated  pneumonia  (VAP)  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  Acinetobacter  spp.  and  when  initial  antibiotic  therapy  is  inappropriate.The  predominant  organisms  responsible  for  infection  are  Staphylococcus  aureus,  P.  aeruginosa,  and  Enterobacteriaceae,  but  etiologic  agents  differ  widely  according  to  the  population  of  hospital  patients,  duration  of  hospital  stay,  and  prior  antimicrobial  therapy.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  multiresistant  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  always  should  be  obtained  before  new  antibiotics  are  administered.Bronchoscopic  techniques,  when  performed  before  introduction  of  new  antibiotics,  enable  physicians  to  identify  most  patients  who  need  immediate  treatment  and  help  to  select  optimal  therapy  in  a  manner  that  is  safe  and  well  tolerated.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.Once  the  microbiologic  data  become  available,  antimicrobial  therapy  should  be  re-evaluated  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  or  even  reduced  to  a  single  agent  in  light  of  the  susceptibility  pattern  of  the  causative  pathogens  without  risking  inappropriate  treatment.Some  very  simple,  no-cost  measures,  such  as  judicious  use  and  prompt  removal  of  a  useless  nasogastric  tube,  removal  of  ventilator  tubing  condensates  with  minimal  exposure  to  patients,  placement  of  ventilated  patients  in  a  semirecumbent  position,  prevention  of  sinusitis,  and  use  of  sucralfate  instead  of  H2  blockers,  may  have  an  impact  on  the  frequency  of  VAP.