II. Epidemiology
III. Pathophysiology
- Oropharyngeal secretion leakage around Endotracheal Tube and into Bronchi and lungs
IV. Causes
- Early-onset (<5 days of hospitalization): Unlikely to multi-drug resistant
- Late-onset (>5 days of hospitalization): Multi-drugs resistance suspected
- Methicillin-Resistant Staphylococcus Aureus (MRSA)
- Multi-drug resistant Gram-Negative Bacteria (80% of cases)
- ESKAPE (E. coli, Serratia, Klebsiella, Acinetobacter, Pseudomonas, Enterobacter)
V. Diagnosis: Ventilator-Associated Pneumonia
- Onset of Pneumonia after 48 hours of Mechanical Ventilation AND
- Chest XRay findings consistent with Pneumonia (new or progressive Pulmonary Infiltrates) AND
- Two of three findings (fever, increased WBC Count, purulent tracheal secretions)
VI. Labs
- Tracheal aspirate or lavage fluid culture and Gram Stain (all cases)
VII. Managment: Mild to Moderate Pneumonia AND Low Risk for multidrug-resistance (see causes above)
- Duration of Antibiotics: 8 days
- Primary Antibiotics
- Ceftriaxone 1 gram IV every 24 hours
- Ampicillin-sulbactam (Unasyn) 3 grams IV every 6 hours
- Ertapenem 1 gram IV every 24 hours
- Levofloxacin 750 mg IV every 24 hours
- Add coverage for MRSA if suspected
- Vancomycin 15-20 mg/kg IV every 8-12 hours
VIII. Management: Severe Pneumonia OR High Risk of multi-drug resistance (see causes above)
- Duration of Antibiotics: 14 days
- Use dual Antibiotics (one from each group of options)
-
Antibiotic 1 Options
- Vancomycin 15-20 mg/kg IV every 8-12 hours (preferred)
- Linezolid 600 mg IV every 12 hours
-
Antibiotic 2 Options
- Cefepime 2 grams IV every 12 hours
- Piperacillin-Tazobactam (Zosyn) 4.5 grams every 6 hours
- Meropenem 1 gram every 8 hours
IX. Prevention
- Consider alternatives to intubation and Mechanical Ventilation
- Consider noninvasive Positive Pressure Ventilation
- Avoid Extubation and reintubation
- Keep respiratory equipment disinfected or sterile
- Keep the head of the bed in semirecumbent position (30-45 degrees)
- Practice antiseptic oral care (with Chlorhexidine mouthwash or gel)
- Avoid acid blocking agents (e.g. H2 Blockers or Proton Pump Inhibitors) if possible
- Typically used to reduce the risk of Stress Ulcers in mechanically ventilated patients
- However, increases the risk of Ventilator-Associated Pneumonia
- Maximize Analgesics and minimize Sedatives
- See Post-Intubation Sedation and Analgesia
- Shortens Mechanical Ventilation duration by up to 2 to 4 days
- Avoid Benzodiazepines if possible
-
Endotracheal Tube Cuff Pressure
- Maintain cuff pressure at 20-30 cm H2O
- Cuff Pressure <20 cm H2O is associated with VAP
- Subglottic suction
- Consider Endotracheal Tubes with subglottic suction ports
- Suction can be set to intermittent or continuous
- Reduces VAP risk by 49%
- Dezfulian (2005) Am J Med 118(1):11-18 [PubMed]
X. Complications
- Mortality: 10% overall, mortality rates approach 30-70% in some studies
- Prolonged Mechanical Ventilation and hospital stays
XI. References
- Gilbert (2014) Sanford Antibiotic Guide, Iphone App
- Roginski, Hogan and Buscher (2020) Crit Dec Emerg Med 34(6): 17-27
- Cagle (2022) Am Fam Physician 105(3): 262-70 [PubMed]
- Coffin (2008) Infect Control Hosp Epidemiol 29(suppl 1): S31-40 [PubMed]
- Hsu (2014) Am Fam Physician 90(6): 377-82 [PubMed]
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Related Studies
Definition (MSH) | Serious INFLAMMATION of the LUNG in patients who required the use of PULMONARY VENTILATOR. It is usually caused by cross bacterial infections in hospitals (NOSOCOMIAL INFECTIONS). |
Concepts | Disease or Syndrome (T047) |
MSH | D053717 |
ICD9 | 997.31 |
ICD10 | J95.851 |
SnomedCT | 429271009 |
English | Pneumonia, Ventilator Associated, Pneumonia, Ventilator-Associated, Ventilator Associated Pneumonia, Ventilator-Associated Pneumonia, Ventilator-acquired pneumonia, Ventilator-acquired pneumonia (disorder), Ventilator-associated pneumonia, Ventltr assoc pneumonia, ventilator-associated pneumonia (diagnosis), ventilator-associated pneumonia, ventilator-associated pneumonia (VAP), ventilator associated pneumonitis, pneumonitis ventilator associated, Ventilator associated pneumonitis, Pneumonia, Ventilator-Associated [Disease/Finding], Ventilator associated pneumonia |
Dutch | ventilator-geassocieerde pneumonie |
French | Pneumonie associée à un ventilateur, PVA (Pneumonie sous Ventilation Assistée), Pneumopathie infectieuse sous ventilation assistée, Pneumonie sous ventilation assistée, Pneumopathie sous ventilation assistée |
German | beatmungsassoziierte Pneumonie, Ventilatorassoziierte Lungenentzündung, Beatmungs-assoziierte Pneumonie, Beatmungspneumonie, Ventilatorassoziierte Pneumonie, Ventilator-assoziierte Pneumonie, Ventilator-assoziierte Lungenentzündung |
Italian | Polmonite associata al ventilatore, Polmonite associata al ventilatore polmonare |
Portuguese | Pneumonia associada a ventilador, Pneumonia Associada ao Ventilador, Pneumonia Associada à Ventilação Mecânica, Pneumonia Associada ao uso de Ventiladores Artificiais, Pneumonia Associada ao uso de Ventiladores Pulmonares, Pneumonia Associada a Respirador, Pneumonia Associada a Respirador Mecânico |
Spanish | Neumonía asociada a ventiloterapia, Neumonia Asociada al Ventilador, Neumonía del Ventilador, neumonía asociada con el uso de respirador (trastorno), neumonía asociada con el uso de respirador |
Russian | ПНЕВМОНИЯ ВЕНТИЛЯТОР-АССОЦИИРОВАННАЯ, ПНЕВМОНИЯ, ВЫЗВАННАЯ ИСКУССТВЕННЫМ ДЫХАНИЕМ, PNEVMONIIA, VYZVANNAIA ISKUSSTVENNYM DYKHANIEM, PNEVMONIIA VENTILIATOR-ASSOTSIIROVANNAIA |
Swedish | Respiratorassocierad pneumoni |
Japanese | ジンコウコキュウキカンレンハイエン, 肺炎-ベンチレータ関連, ベンチレータ関連肺炎, 人工呼吸器関連肺炎, 肺炎-人工呼吸器関連 |
Finnish | Hengityskonehoitoon liittyvä keuhkokuume |
Czech | Zánět plic souvisící s ventilátorem, ventilátorová pneumonie, pneumonie ventilátorová |
Polish | Zapalenie płuc związane z mechaniczną wentylacją, Zapalenie płuc respiratorowe |
Hungarian | Lélegeztetéshez kapcsolódó pneumonia |
Norwegian | Respiratorassosiert pneumoni, Ventilatorassosiert pneumoni, VAP |