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ventilator-associated pneumonia

Pneumonia that develops > 48-72 hours after initiation of mechanical ventilation. Etiology: risk factors 1) mechanical ventilation, endotracheal intubation - longer duration of mechanical ventilation 2) advanced age (>= 70 years of age) 3) depressed level of consciousness 4) pre-existing lung disease (COPD) 5) immunosuppression 6) malnutrition 7) supine position [4] 8) enteral nutrition [4] 9) risk factors for antibiotic-resistant organisms - concurrent septic shock - preceding ARDS - >= 5 days of preceding hospitalization - preceding renal replacement therapy - intravenous antibiotics within 90 days [15] Epidemiology: - 10 % of mechanically ventilated patients - incidence unchanged 2005-2013 [9] - 55% of ventilator-associated pneumonia may be preventable [4] Clinical manifestations: 1) fever (> 38.0 C) 2) increased respiratory secretions, purulent sputum, or change in character of sputum 3) cough, dyspnea or tachypnea 4) rales or bronchial breath sounds 5) worsening gas exchange 6) delirium in the elderly Laboratory: 1) complete blood count may show leukocytosis with left shift or leukopenia 2) culture of tracheal aspirate 3) blood cultures 3) arterial blood gas [paO2/FiO2 < 240] &/or decrease in SaO2 * also see ARUP consult [11] Special laboratory: 1) bronchoscopy may be useful for obtaining a specimen for culture 2) lung biopsy in rare cases for obtaining a specimen for culture Radiology: 1) new or progressive infiltrate on chest X-ray 2) consoidation or cavitation Management: 1) antibiotics, guided by culture & antimicrobial sensitivity a) multiple antibiotic resistance is common b) 8 days of therapy equivalent to 15 days* [3,6,12] - 6 days of therapy equivalent to 14 days* [17] c) 1 week (7 days) of therapy* [4] d) optimal duration of therapy for Pseudomonas pneumonia is 7 days [10] - Pseudomonas & other gram-negative bacilli may require a longer duration of therapy (10-14 days) [4,6]; apparently not so [10] e) empiric therapy should cover Staphylococcus aureus, Pseudomonas aeruginosa, other non-fermenting gram-negative bacteria & MRSA if risk factors [4] - ceftazidime, levofloxacin plus vancomycin [4] - cefepime, ciprofloxacin* or levofloxacin plus vancomycin - two agents of different classes to cover Pseudomonas - single agent appropriate if antibiotic sensitivity known [15] f) carbapenems are appropriate for empiric therapy due to extended spectrum beta lactamase producing gram-negative bacilli [4] - meropenem vaborbactam & imipenem relebactam FDA-approved [13] g) other FDA-approved antibacterial agents - ceftobiprole, ceftolozane tazobactam, cefiderocol [13] h) see pneumonia i) if patient does not improve within 3 days of appropriate antibiotic therapy, consider alternate diagnosis or unrecognized source of infection - consider mycoses, candidemia if Candida isolated from not urinary source - add coverage with caspofungin or other echinocandin 2) supportive care a) prolonged mechanical ventilation b) intensive care unit 3) prevention a) hand washing before & after patient contact b) avoid nasal intubation & nasogastric tube [4] c) maintain head at >= 30 degree position (30-45 degrees) [4] d) minimize duration of mechanical intubation - daily assessment of readiness for extubation [15] - follow daily weaning protocols to expedite extubation [4] e) conversion of tracheostomy when ventilation is needed longer term f) proper endtracheal tube cuff pressures to prevent aspiration from gastroesophageal reflux g) enteral rather than parenteral feeding h) glycemic control in diabetics i) minimize sedation j) oral hygiene: chlorhexidine mouth rinse & subglottic suction - toothbrushing associated with lower risk of ventilator-associated pneumonia [16] k) early mobility [4] l) data on use of probiotics to prevent ventilator-associated pneumonia conflicting [13,14] * ciprofloxacin is not a respiratory fluoroquinolone, but it does penetrate into lung tissue & may be the most effective fluoroquinolone against Pseudomonas * not due to non-fermenting Gram-negative bacilli (Pseudomonas, Stenotrophomonas maltophilia, Acinetobacter spp*) [6] * 8 days of therapy adequate for Acinetobacter [6]

Related

mechanical ventilation (assisted ventilation)

General

nosocomial pneumonia; hospital-acquired pneumonia; health care-associated pneumonia

References

  1. Torpy JM, JAMA patient page. Ventilator-associated pneumonia. JAMA 2007, 297:1616 PMID: 17426282
  2. Klompas M, Does this patient have ventilator-associated pneumonia? JAMA 2007, 297:1583 PMID: 17426278
  3. Journal Watch 24(2):10, 2004 Chastre J et al, Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA 290:2588, 2003 PMID: 14625336
  4. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  5. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005 Feb 15;171(4):388-416. PMID: 15699079
  6. Pugh R, Grant C, Cooke RP, Dempsey G. Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults. Cochrane Database Syst Rev. 2011 Oct 5;(10):CD007577 PMID: 21975771 - Pugh R, Grant C, Cooke RP et al Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults. Cochrane Database Syst Rev. 2015(8):CD007577 PMID: 26301604 PMCID: PMC7025798 Free PMC article https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007577.pub3/full
  7. Kalanuria AA, Zai W, Mirski M. Ventilator-associated pneumonia in the ICU. Crit Care. 2014 Mar 18;18(2):208. Review. PMID: 25029020 Free PMC Article
  8. Klompas M, Branson R, Eichenwald EC et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Aug;35(8):915-36. PMID: 25026607
  9. Metersky ML et al. Trend in ventilator-associated pneumonia rates between 2005 and 2013. JAMA 2016 Nov 11 PMID: 27835709
  10. Kalil AC, Metersky ML, Klompas M et al 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. PMID: 27418577 PMCID: PMC4981759 Free PMC Article
  11. ARUP Consult: Hospital-Acquired and Ventilator-Associated Pneumonia The Physician's Guide to Laboratory Test Selection & Interpretation https://arupconsult.com/content/healthcare-associated-pneumonia
  12. Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  13. Rapid Review Quiz: Hospital-Acquired Pneumonia Medscape. Sept 15, 2022 https://reference.medscape.com/viewarticle/980567
  14. Johnstone J, Meade M, Lauzier F et al. Effect of probiotics on incident ventilator-associated pneumonia in critically ill patients: A randomized clinical trial. JAMA 2021 Sep 21; 326:1024. PMID: 34546300 https://jamanetwork.com/journals/jama/article-abstract/2784358
  15. NEJM Knowledge+
  16. Ehrenzeller S, Klompas M. Association between daily toothbrushing and hospital-acquired pneumonia: A systematic review and meta-analysis. JAMA Intern Med 2023 Dec 18; [e-pub] PMID: 38109100. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2812938
  17. Mo Y et al. Individualised, short-course antibiotic treatment versus usual long-course treatment for ventilator-associated pneumonia (REGARD-VAP): A multicentre, individually randomised, open-label, non-inferiority trial. Lancet Respir Med 2024 May; 12:399. PMID: 38272050 Free article https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(23)00418-6/fulltext