In patients with VAP or HAP caused by Acinetobacter species, the guidelines consider carbapenems, ampicillin/sulbactam, and colistin to be equally effective for treating susceptible isolates.
Full Answer
What is VAP and what is it for?
Are you wondering exactly what is VAP ? Let’s dig into it a little deeper. VAP stands for Ventilator-Associated Pneumonia and is basically pneumonia that develops 48 hours or longer after mechanical ventilation is initiated on a patient. What is the problem with VAP?
What is a VAP infection?
VAP stands for Ventilator-Associated Pneumonia and is basically pneumonia that develops 48 hours or longer after mechanical ventilation is initiated on a patient. What is the problem with VAP?
How are Hap and VAP pneumonias treated?
Although HAP and VAP have traditionally been treated with longer durations of antimicrobial therapy, the current guidelines recommend a 7-day course of antibiotic therapy for the treatment of these types of pneumonias regardless of the pathogen (s) causing infection.
What is ventilator-associated pneumonia (VAP)?
Ventilator-associated pneumonia is defined as pneumonia occurring more than 48 h after patients have been intubated and received mechanical ventilation. Diagnosing VAP requires a high clinical suspicion combined with bedside examination, radiographic examination, and microbiologic analysis of respiratory secretions.
What is the treatment for VAP?
Generally, a week of antibiotic therapy is sufficient for the treatment of VAP. In a double-blind clinical trial conducted in 51 French intensive care units or ICUs that included 401 patients with VAP, patients were randomized to 8 or 15 days of antibiotic therapy.
What is the main cause of VAP?
The common pathogens of VAP are Gram-negative bacilli including Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, and Acinetobacter, and Gram-positive cocci such as Staphylococcus aureus. Pseudomonas aeruginosa is the most common pathogen of VAP (Evans et al., 2018; Rhodes et al., 2018).
What is VAP prevention?
To reduce risk for VAP, the following nurse-led evidence-based practices are recommended: reduce exposure to mechanical ventilation, provide excellent oral care and subglottic suctioning, promote early mobility, and advocate for adequate nurse staffing and a healthy work environment.
What is VAP ICU?
Ventilator-associated pneumonia (VAP) is defined by infection of the pulmonary parenchyma in patients exposed to invasive mechanical ventilation for at least 48 h and is part of ICU-acquired pneumonia. VAP remains one of the most common infections in patients requiring invasive mechanical ventilation.
Why is VAP overtreatment?
Due to poor specificity and poor positive predictive value, reliance on clinical parameters, chest X-ray findings, and non- and semiquantitative sputum analysis will result in overdiagnosis and therefore overtreatment of VAP. Such an approach will result in excess antibiotic use with its attendant cost, potential toxicity, and selection of drug-resistant organisms. A recent decision analysis suggested that more deaths occurred if patients were treated with antibiotics on the basis of only clinical suspicion of VAP than if antibiotics were withheld (190).
What is ventilator-associated pneumonia?
Ventilator-associated pneumonia is usually suspected when the individual develops a new or progressive infiltrate on chest radiograph, leukocytosis, and purulent tracheobronchial secretions. Unfortunately, and unlike for community-acquired pneumonia, accepted clinical criteria for pneumonia are of limited diagnostic value in definitively establishing the presence of VAP. In a postmortem study by Fabregas et al., when findings on histologic analysis and cultures of lung samples obtained immediately after death were used as references, a new and persistent (>48-h) infiltrate on chest radiograph plus two or more of the three criteria (i) fever of >38.3°C, (ii) leukocytosis of >12 × 109/ml, and/or (iii) purulent tracheobronchial secretions had a sensitivity of 69% and a specificity of 75% for establishing the diagnosis of VAP (60). When all three clinical variables were required for the diagnosis, the sensitivity declined further (23%); the use of a single variable resulted in a decrease in specificity (33%). The poor accuracy of clinical criteria for diagnosing VAP should not be surprising considering that purulent tracheobronchial secretions are invariably present in patients receiving prolonged mechanical ventilation and are seldom caused by pneumonia. In addition, the systemic signs of pneumonia such as fever, tachycardia, and leukocytosis are nonspecific; they can be caused by any state that releases the cytokines interleukin-1, interleukin-6, tumor necrosis factor alpha, and gamma interferon (33, 34, 63, 135). Examples of such conditions include trauma, surgery, the fibroproliferative phase of ARDS, deep vein thrombosis, pulmonary embolism, and pulmonary infarction. Reasonable clinical criteria for the suspicion of VAP include a new and persistent (>48-h) or progressive radiographic infiltrate plus two of the following: temperature of >38°C or <36°C, blood leukocyte count of >10,000 cells/ml or <5,000 cells/ml, purulent tracheal secretions, and gas exchange degradation (5, 103).
Where to sample for pulmonary infiltrate?
When in doubt, sample the posterior right lower lobe, since autopsy studies have indicated that VAP frequently involves this area (61, 92, 130, 173). Multiple specimens are no more accurate than single specimens (136).
Is VAP a sensitivity?
The sensitivity of the clinical criteria for VAP outlined above is even lower in patients with ARDS, where it may be difficult to detect new radiographic infiltrates. In the setting of ARDS, Bell et al. reported a false-negative rate of 46% for the clinical diagnosis of VAP (11). Consequently, suspicion for VAP in the setting of ARDS should be high. The presence of even one of the clinical criteria for VAP, unexplained hemodynamic instability, or an unexplained deterioration in arterial blood gases should prompt consideration of further diagnostic testing (129).
How to treat VAP?
Basically, you treat VAP with proper antibiotics. Medications that are prescribed should match the bacteria that is present. Initially, while no information about the causative agent is available, a broad-spectrum antibiotic would be administered until culture and sensitivity results are available.
How to diagnose a patient with VAP?
That’s because the patients are already intubated and in a serious condition and you really do not want or need to cause any more harm.
What are the causes of ventilator-associated pneumonia?
The declined state of the immune system can be due to different factors such as immunosuppressive medications, underlying diseases, and an altered mental state.
What is the problem with VAP?
An infection is described as a breach in a body’s defense system by harmful microorganisms such as bacteria, viruses, and parasites which are not part of the normal flora (the naturally occurring bacteria of the human body). Once an infiltration is made, microbes would start proliferating which can lead to certain diseases.
How to prevent ventilator pneumonia?
About one-third of all ventilator-associated pneumonia cases in the United States could be prevented. For healthcare providers, the CDC released some of the things that we can do to prevent VAP. This includes: 1 Use NPPV (non-invasive positive pressure ventilation) whenever possible, as this significantly decreases the chances of VAP as opposed to intubation and mechanical ventilation. 2 Use daily weaning trials to assess the patient’s respiratory muscle strength and ability to be removed from the ventilator. The risk of VAP is associated with the length of time on the ventilator, so naturally, if you can decrease that amount of time, you will decrease the chances of VAP. 3 Elevate the head position of the bed. This has been shown to reduce the chances of gastric aspiration, which causes VAP. Strive to keep the head of the bed elevated to 45 degrees. 4 Use proper hand hygiene. This goes without saying, however, you should always wash your hand with soap and water upon entering the patient’s room, then again once you leave the room. 5 Practice oral decontamination on the patient by doing mouth-care regularly. Cleaning out the bacteria in the mouth decreases that chances of VAP significantly. 6 Don’t break the circuit of the ventilator. Keeping the circuit closed as much as possible has been shown to decrease the chances of the patient obtaining VAP. This means that you should change the circuit only when it is visibly soiled.
How long does it take for a VAP to develop?
The first one is the early-onset VAP which happens 48 to 96 hours (4 days) after intubation. It is caused by an antibiotic-sensitive bacterium. The second is late-onset VAP, which develops after 4 days from when the patient is initially intubated. It is usually caused by an antibiotic-resistant bacterium.
How can ventilator-associated pneumonia be acquired?
These pathogens can be acquired through contaminated medical equipment, hands, and even the uniforms of medical providers.
What is empirical therapy for ventilator-associated pneumonia?
Once ventilator-associated pneumonia is suspected and appropriate culture samples are sent, empirical therapy will be based on the duration of intubation and hospitalization, prior or current antibiotic therapy , the severity of clinical disease, and knowledge of local pathogen’s susceptibility patterns. Initial broad-spectrum therapy with coverage of gram-negative bacilli, including P. aeruginosa, and possibly methicillin-resistant S. aureusis generally appropriate. Treatment is then narrowed based on subsequent culture data and clinical and radiographic findings. [12][13][14]
What is ventilator-associated pneumonia?
Ventilator-associated pneumonia (VAP) is a term used to describe pneumonia (lung infection) that develops in a patient who has been on mechanical ventilation for more than 48 hours. Ventilator-associated pneumonia is the second most common hospital-acquired infection among pediatrics and neonatal intensive care unit patients. It accounts for 7% to 32% of healthcare-associated infections and 10% of all pediatric device-related infections reported to the National Healthcare Safety Network (NHSN). Generally, the rate of pneumonia in pediatric intensive care units (PICU) is lower than in adult intensive care units (ICU). In neonates, the rate of ventilator-associated pneumonia is inversely proportional to birth weight. There is limited data on infants and children with VAP, so most of the information is extrapolated from adult studies. [1][2][3]
Does VAP cause higher mortality?
In general, VAP is associated with a higher mortality when the patient has numerous comorbidities. However, younger patients with no additional organ involvement do tend to have a good prognosis without any major sequelae. Higher mortality rates have been reported in older patients, diabetics, those with COPD, smokers and poor functional status. [17][18](Level V)
Is ventilator-associated pneumonia bacterial?
Ventilator-associated pneumonia is typically bacterial and from a single organism. However polymicrobial infections are increasing. In a large retrospective review done in the ICU settings of three hospitals, the microbiology was the same across adult and pediatric hospitals. The most common organisms were Staphylococcus aureus(28.4 %), Pseudomonas aeruginosa(25.2 %), and other gram negatives (26.6%). [4][5]
Can pneumonia be diagnosed with a ventilator?
Diagnosis of ventilator-associated pneumonia can be difficult. It requires a combination of clinical, radiographic, and microbiologic data. The longer the length of intubation, the higher the likelihood of ventilator-associated pneumonia. Ventilator-associated pneumonia is suspected in the setting of fever, change in auscultation exam, a change in the chest x-ray, and an increasing requirement for respiratory support. However, auscultation is hindered by sounds of the ventilation system itself, especially with high-frequency ventilation. Many neonates have chest x-ray findings that interfere with the early detection of new infiltrates.
When is VAP most likely to occur?
The highest risk of VAP occurs during the first 10 days after intubation. Ventilator-associated pneumonia occurs in 9 to 27% of mechanically ventilated patients.
What are the risk factors for VAP?
Other risk factors for antibiotic-resistant organisms specific to VAP include. Septic shock at time of VAP. Acute respiratory distress syndrome (ARDS) preceding VAP. Hospitalization for ≥ 5 days prior to the occurrence of VAP.
What are the most important pathogens in antibiotic resistance?
In general, the most important pathogens are Pseudomonas aeruginosa, methicillin-sensitiv e Staphylococcus aureus, and methicillin-resistant S. aureus (MRSA).
What is the most common pathogen in ventilator-associated pneumonia?
The most common pathogens are gram-negative bacilli and Staphylococcus aureus; antibiotic-resistant organisms are an important concern. In ventilated patients, pneumonia usually manifests as fever, increase in white blood cell count, worsening oxygenation, and increased tracheal secretions that may be purulent. Diagnosis is suspected on the basis of clinical presentation and chest x-ray and is sometimes confirmed by a positive blood culture for the same pathogen found in respiratory secretions or bronchoscopic sampling of the lower respiratory tract with quantitative Gram stain and cultures. Treatment is with antibiotics. Overall prognosis is poor, due in part to comorbidities.
Why is continuous aspiration of subglottic secretions used?
Continuous aspiration of subglottic secretions using a specially designed endotracheal tube attached to a suction device seems to reduce the risk of microaspiration and the incidence of VAP.
How to prevent ventilator pneumonia?
There are a number of measures that can help prevent ventilator-associated pneumonia. Semiupright or upright positioning reduces risk of aspiration and pneumonia compared with recumbent positioning and is the simplest and most effective preventive method.
How long after initiation of antibiotics should you reassess?
Reassess patients 2 to 3 days after initiation of treatment, and change antibiotics based on available culture and clinical data.
What can a pharmacist do for a patient with VAP?
Pharmacists can play an integral role in the management of patients with VAP and HAP. Pharmacists can work with their microbiology laboratory to create an institution-specific antibiogram, regularly update its contents, and educate clinicians about its use. Pharmacists should work with clinicians to select the most appropriate empiric antimicrobial regimen for a patient with VAP or HAP based on the patient’s risk factors for antimicrobial-resistant pathogens. Pharmacists are also in a key position to recommend de-escalation of antimicrobial regimens and to ensure that patients are receiving the appropriate duration of therapy for these types of infections.
What is a VAP?
V entilator-associated pneumonia (VAP) is defined as pneumonia that develops in patients receiving mechanical ventilation that occurs at least 48 hours after endotracheal intubation. 1 Hospital-acquired pneumonia (HAP) is defined as pneumonia not associated with mechanical ventilation that occurs at least 48 hours after a patient has been admitted to the hospital and that was not incubating at the time of admission. 1 A multistate prevalence survey from 2014 found that pneumonia was responsible for 21.8% of healthcare-associated infections. 2 Although the mortality rate attributable to VAP varies with patient characteristics, recent data reports an estimated mortality of approximately 10%. 3 Additionally, patients with VAP have prolonged durations of mechanical ventilation, intensive-care unit (ICU) stays, and hospital stays, as well as almost $40,000 in excess mean hospitalization costs as compared with patients without VAP. 4,5
What antibiotics should I use for HAP?
For empiric treatment of HAP in patients with no risk factors for MRSA infection who are not at high risk for mortality, the guidelines recommend using an antibiotic with activity against MSSA and a regimen that includes piperacillin/tazobactam, cefepime, levofloxacin, imipenem, or meropenem. For patients with HAP who have prior intravenous antibiotic use within 90 days, a high risk for mortality, or structural lung disease (i.e., bronchiectasis or cystic fibrosis), double antipseudomonal coverage with antibiotics from two different classes should be considered. Again, a beta-lactam–based agent is typically used in combination with a fluoroquinolone when double gram-negative coverage is required. Patients who do not meet the criteria for double antipseudomonal coverage may be treated with a single antimicrobial agent that has activity against P aeruginosa. However, the guidelines recommend against using an aminoglycoside as the sole antipseudomonal agent due to poor lung penetration and adverse effect profile. 1
What is the empiric regimen for MRSA?
For patients with suspected VAP who do not meet criteria for MRSA coverage, the guidelines suggest an empiric regimen that includes piperacillin/tazobactam, cefepime, levofloxacin, imipenem, or meropenem.
What is the best antibiotic for ESBL?
Antimicrobial susceptibility testing provides the best information to inform antibiotic choices, as there is no preferred antibiotic regimen for patients with confirmed VAP or HAP caused by gram-negative bacilli that produce extended-spectrum beta-lactamase (ESBL). The guidelines acknowledge that carbapenems are generally considered to be the agents of choice for ESBL infections, but report that there is also data suggesting that piperacillin/tazobactam or cefepime may be appropriate for the treatment of certain isolates. The guidelines state that there is an urgent research need for studies that compare antibiotic regimens for the treatment of pneumonia caused by ESBL-producing organisms. 1
What is the best method to test for VAP?
The guidelines recommend obtaining cultures of respiratory secretions and blood cultures from all patients with suspected HAP or VAP in order to guide antimicrobial treatment. Noninvasive sampling (such as endotracheal aspiration and sputum expectoration) with semiquantitative culture results (with growth of microorganism (s) reported as light/few, moderate, or abundant/many) is recommended for diagnosis of patients with suspected VAP and HAP. These methods are preferred over invasive bronchoscopic techniques such as bronchoalveolar lavage (BAL) or protected specimen brush (PSB), or noninvasive sampling with quantitative culture results (growth thresholds considered significant at 10 3 colony-forming units [CFU]/mL for PSB or 10 4 CFU/mL for BAL), for the diagnosis of HAP or VAP. The rationale for recommending noninvasive sampling with semiquantitative culture results is that these methods can be performed more rapidly, require fewer resources, and are associated with fewer complications than using invasive sampling techniques and reporting quantitative results. For those patients with suspected pneumonia in whom invasive cultures with quantitative results are performed, antibiotics may be discontinued if quantitative culture results are below the diagnostic threshold. 1
What is de-escalation in antimicrobial therapy?
De-escalation is an important component of antimicrobial stewardship and refers to changing from a broad-spectrum antimicrobial regimen to one that has a narrower spectrum of activity or changing from combination therapy to monotherapy.
Does a drug have multiple schedules?
The drug has multiple schedules. The schedule may depend on the exact dosage form or strength of the medication.
Is abuse a low potential for abuse relative to those in Schedule 4?
Has a low potential for abuse relative to those in schedule 4. Has a currently accepted medical use in treatment in the United States. Abuse may lead to limited physical dependence or psychological dependence relative to those in schedule 4.