Ventilator-associated pneumonia - Guideline for the Management of |
Publication: 01/01/2009 |
Next review: 17/10/2023 |
Clinical Guideline |
UNDER REVIEW |
ID: 1544 |
Approved By: Improving Antimicrobial Prescribing Group |
Copyright© Leeds Teaching Hospitals NHS Trust 2020 |
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated. |
Guideline for management of ventilator-associated pneumonia
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Background |
Ventilator-associated pneumonia [VAP] is a form of hospital acquired pneumonia. VAP is defined as pneumonia developing at least 48 hours after implementing endotracheal intubation and/or mechanical ventilation that was not present before intubation (Masterton et al., 2008). VAP is a serious healthcare associated infection with a mortality rate between 24-76% depending on the pathogen involved (Masterton et al., 2008). VAP is not uncommon and accounts for a quarter of intensive care unit infections (Masterton et al., 2008). The lack of gold standard for the diagnosis of VAP has made assessment of diagnostic and treatment strategies problematic (Anon, 2005; Masterton et al., 2008). However, in practical terms, VAP can be classified as early or late onset. This classification has relevance to the causative organism and therefore to empirical therapy. In this guideline early onset VAP is defined as that developing within four days of hospital admission and late onset VAP is defined as that occurring after five days or more (Anon, 2005). The risk of developing VAP is highest in the first five days of ventilation. The microbiology of VAP is complex. In early onset VAP, the usual pathogens associated with community acquired pneumonia and more sensitive hospital acquired bacteria predominate e.g. Escherichia coli, Klebsiella spp. Streptococcus pneumoniae and meticillin sensitive Staphylococcus aureus. In late onset VAP multi-resistant pathogens become more prominent including meticillin resistant Staphylococcus aureus, extended-spectrum beta-lactamase producing coliforms, Pseudomonas aeruginosa and Acinetobacter spp. This guideline is concerned with the management of VAP, not its prevention which is the subject of ventilation care bundles. Patients who develop pneumonia <48 hours after intubation or who already have pneumonia at the time of intubation should be treated according to the LTHT community acquired pneumonia guidelines or LTHT hospital acquired pneumonia guidelines as appropriate. Aspects of this guideline may not be appropriate for neutropenic or severely immunocompromised patients who should be discussed with a microbiologist. These are guidelines and an alternative approach may be necessary in individual cases following discussion with a microbiologist. |
Investigation |
Chest X-ray. Respiratory tract sampling for microbiology Bronchoalveolar lavage [BAL] samples, whether “blind” or derived via bronchoscopy are equally useful in the microbiological diagnosis of VAP. Either method can be used in suspected cases of VAP (Masterton et al., 2008) [Evidence level A]. Quantitative cultures of BAL samples do not improve the diagnosis of VAP. (Masterton et al., 2008). [Evidence level A] BAL samples will have direct microscopy and be cultured semi-quantitatively: a heavy [+++] “pure” culture of a recognized pathogenic bacterial species should be considered as likely to be significant in the appropriate clinical setting. Other result should be interpreted with caution. [Evidence level D] Blood cultures Other microbiology samples Full blood count Clinical chemistry Recommendations regarding CRP measurement do not appear in current guidelines (Anon, 2005; Masterton et al., 2008) but local opinion is that a normal CRP would be very unlikely in a case of VAP. CRP should be measurement at baseline and to monitor response to therapy is recommended. [Evidence level D] |
Treatment | ||||||||||||||||||||||||||||||||||||||||
Non-Antimicrobial Treatment | ||||||||||||||||||||||||||||||||||||||||
As directed by consultant in intensive care and ventilator care bundles. |
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Empirical Antimicrobial Treatment | ||||||||||||||||||||||||||||||||||||||||
Antimicrobial therapy should not be delayed while waiting for results of BAL samples. (Masterton et al., 2008) [Evidence level C] The results of prior BAL and other microbiology samples should be taken into consideration when choosing empirical therapy [e.g. MRSA colonization]. [Evidence level D] The empirical antimicrobial therapy of VAP is determined by the duration of time in hospital (Anon, 2005; Masterton et al., 2008). [Evidence level C] A. Early onset VAP [≤4 days in hospital] AND not currently on antimicrobials AND <24 hours antimicrobial therapy in the last week. 1. Patients who do NOT have severe sepsis or septic shock Substitute Cefuroxime Substitute Levofloxacin 2. Patients who have severe sepsis or septic shock Substitute Levofloxacin B. Early onset VAP [≤4 days in hospital] and on antimicrobials or >24 hours antimicrobial therapy in the last week. 1. Patients who do not have severe sepsis or septic shock 2. Patients who have severe sepsis or septic shock Substitute Levofloxacin C. Late onset VAP [≥5 days in hospital] 1. Patients who do not have severe sepsis or septic shock [N.B. Recent Piperacillin/tazobactam 2. Patients who have severe sepsis or septic shock Substitute Linezolid MRSA #Linezolid
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Directed Antimicrobial Treatment (when microbiology results are known) | ||||||||||||||||||||||||||||||||||||||||
Empirical antimicrobial therapy should be reviewed daily with microbiology results and converted to directed therapy wherever possible [Evidence level C]. If no pathogen[s] have been isolated consider if antimicrobial[s] are still indicated. [Evidence level C] If Linezolid Table 1. Directed antimicrobial regimens for VAP.
*review doses with renal function. #Linezolid |
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Duration of Treatment | ||||||||||||||||||||||||||||||||||||||||
With the exception of infection caused by Pseudomonas aeruginosa, VAP can be treated with 7 days of appropriate antimicrobials, provided there has been a good clinical response (Anon, 2005; Masterton et al., 2008). [Evidence level A] VAP caused by Pseudomonas aeruginosa can be treated with 10-14 days of appropriate antimicrobial monotherapy, provided there has been a good clinical response. [Evidence level D] If aminoglycosides are used to supplement beta-lactam antibiotics for treatment of Pseudomonas aeruginosa VAP then short course aminoglycoside therapy [≤5 days] should be considered.
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Switch to oral agent(s) | ||||||||||||||||||||||||||||||||||||||||
There are no data to guide the switch to oral antimicrobial therapy for VAP, but agents with good oral bioavailability such as Ciprofloxacin |
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Treatment Algorithm | ||||||||||||||||||||||||||||||||||||||||
Treatment Failure | ||||||||||||||||||||||||||||||||||||||||
Please contact microbiology if the patient is not responding to the recommended antimicrobial regimens. |
Provenance
Record: | 1544 |
Objective: |
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Clinical condition: | Ventilator-associated pneumonia |
Target patient group: | Adults |
Target professional group(s): | Secondary Care Doctors Pharmacists |
Adapted from: |
Evidence base
References
Anon (2005). Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. American journal of respiratory and critical care medicine 171, 388-416.
Masterton, R. G., Galloway, A., French, G. & other authors (2008).Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy, pp. 5-34.
Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. [where no guidance exists or there is wide disagreement with a level C recommendation]
Approved By
Improving Antimicrobial Prescribing Group
Document history
LHP version 1.0
Related information
Not supplied
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