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]