II. Epidemiology

  1. Incidence: 9-28% of mechanically ventilated patients
    1. Ventilator-Associated Pneumonia accounts for 20% of all hospital-acquired Pneumonias

III. Pathophysiology

  1. Oropharyngeal secretion leakage around Endotracheal Tube and into Bronchi and lungs

IV. Causes

  1. Early-onset (<5 days of hospitalization): Unlikely to multi-drug resistant
    1. Streptococcus Pneumoniae
    2. Staphylococcus aureus
    3. HaemophilusInfluenzae
    4. Gram Negative Bacteria
  2. Late-onset (>5 days of hospitalization): Multi-drugs resistance suspected
    1. Methicillin-Resistant Staphylococcus aureus (MRSA)
    2. Multi-drug resistant Gram-Negative Bacteria (80% of cases)
      1. ESKAPE (E. coli, Serratia, Klebsiella, Acinetobacter, Pseudomonas, Enterobacter)

V. Diagnosis: Ventilator-Associated Pneumonia

  1. Onset of Pneumonia after 48 hours of Mechanical Ventilation AND
  2. Chest XRay findings consistent with Pneumonia (new or progressive Pulmonary Infiltrates) AND
  3. Two of three findings (fever, increased WBC Count, purulent tracheal secretions)

VI. Labs

  1. 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)

  1. Duration of antibiotics: 8 days
  2. Primary antibiotics
    1. Ceftriaxone 1 gram IV every 24 hours
    2. Ampicillin-sulbactam (Unasyn) 3 grams IV every 6 hours
    3. Ertapenem 1 gram IV every 24 hours
    4. Levofloxacin 750 mg IV every 24 hours
  3. Add coverage for MRSA if suspected
    1. Vancomycin 15-20 mg/kg IV every 8-12 hours

VIII. Management: Severe Pneumonia OR High Risk of multi-drug resistance (see causes above)

  1. Duration of antibiotics: 14 days
  2. Use dual antibiotics (one from each group of options)
  3. Antibiotic 1 Options
    1. Vancomycin 15-20 mg/kg IV every 8-12 hours (preferred)
    2. Linezolid 600 mg IV every 12 hours
  4. Antibiotic 2 Options
    1. Cefepime 2 grams IV every 12 hours
    2. Piperacillin-Tazobactam (Zosyn) 4.5 grams every 6 hours
    3. Meropenem 1 gram every 8 hours

IX. Prevention

  1. Consider alternatives to intubation and Mechanical Ventilation
    1. Consider noninvasive Positive Pressure Ventilation
    2. Avoid Extubation and reintubation
  2. Keep respiratory equipment disinfected or sterile
  3. Keep the head of the bed in semirecumbent position (30-45 degrees)
  4. Practice antiseptic oral care (with Chlorhexidine mouthwash or gel)
  5. Avoid acid blocking agents (e.g. H2 Blockers or Proton Pump Inhibitors) if possible
    1. Typically used to reduce the risk of Stress Ulcers in mechanically ventilated patients
    2. However, increases the risk of Ventilator-Associated Pneumonia
  6. Maximize Analgesics and minimize Sedatives
    1. See Post-Intubation Sedation and Analgesia
    2. Shortens Mechanical Ventilation duration by up to 2 to 4 days
    3. Avoid Benzodiazepines if possible
  7. Endotracheal Tube Cuff Pressure
    1. Maintain cuff pressure at 20-30 cm H2O
    2. Cuff Pressure <20 cm H2O is associated with VAP
  8. Subglottic suction
    1. Consider Endotracheal Tubes with subglottic suction ports
    2. Suction can be set to intermittent or continuous
    3. Reduces VAP risk by 49%
    4. Dezfulian (2005) Am J Med 118(1):11-18 [PubMed]

X. Complications

  1. Mortality: 10% overall, mortality rates approach 30-70% in some studies
  2. Prolonged Mechanical Ventilation and hospital stays

XI. References

  1. Gilbert (2014) Sanford Antibiotic Guide, Iphone App
  2. Roginski, Hogan and Buscher (2020) Crit Dec Emerg Med 34(6): 17-27
  3. Cagle (2022) Am Fam Physician 105(3): 262-70 [PubMed]
  4. Coffin (2008) Infect Control Hosp Epidemiol 29(suppl 1): S31-40 [PubMed]
  5. Hsu (2014) Am Fam Physician 90(6): 377-82 [PubMed]

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Related Studies

Ontology: Pneumonia, Ventilator-Associated (C1701940)

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
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