49 - Ventilator-Associated Pneumonia

Abstract

Ventilator-associated pneumonia (VAP) is the most frequent intensive care unit (ICU)-acquired infection among patients receiving mechanical ventilation. Despite major improvements in its management, VAP remains associated with mortality in excess of that caused by the underlying disease alone, particularly in case of infection caused by high-risk pathogens, such as Pseudomonas aeruginosa, or when initial treatment is inappropriate. The high level of bacterial resistance observed in patients with VAP and the necessity to avoid initial inappropriate antimicrobial therapy limit the treatment options available to clinicians and encourage the use of regimens combining several broad-spectrum antibiotics. Besides its economic impact, this practice of “spiralling empiricism” increasingly leads to the unnecessary administration of antibiotics in many ICU patients without true infection, paradoxically resulting in the emergence of infections caused by more antibiotic-resistant microorganisms that are, in turn, associated with increased rates of patient mortality and morbidity. Every possible effort should therefore be made to obtain reliable pulmonary specimens for direct microscopic examination and cultures from each patient with a clinical suspicion of VAP in order to be able to de-escalate treatment every time it is possible. Consensus, however, on appropriate diagnostic, therapeutic, and preventive strategies for VAP has yet to be reached.