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Ventilator-Associated Pneumonia

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Ventilator-Associated Pneumonia, Ventilator Associated Pneumonia

  • Epidemiology
  1. Incidence: 9-28% of mechanically ventilated patients
    1. Ventilator-Associated Pneumonia accounts for 20% of all hospital-acquired Pneumonias
  • Pathophysiology
  1. Oropharyngeal secretion leakage around Endotracheal Tube and into Bronchi and lungs
  • 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)
  • 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)
  • Labs
  1. Tracheal aspirate or lavage fluid culture and Gram Stain (all cases)
  • 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
  • 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
  • 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)
  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. 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]
  • Complications
  1. Mortality: 30-70%
  2. Prolonged Mechanical Ventilation and hospital stays
  • References
  1. Gilbert (2014) Sanford Antibiotic Guide, Iphone App
  2. Roginski, Hogan and Buscher (2020) Crit Dec Emerg Med 34(6): 17-27
  3. Coffin (2008) Infect Control Hosp Epidemiol 29(suppl 1): S31-40 [PubMed]
  4. Hsu (2014) Am Fam Physician 90(6): 377-82 [PubMed]