Ventlator Associated Pneumonia (VAP)

Good reviews are available here and here.

Diagnosis:

10-20% of patients receiving mechanical ventilation for more than 48 hours will develop VAP

Some controversy exists about how to precisely define the diagnosis. However in general if you have a new or worsening CXR infiltrate with two or more of:

• Fever or hypothermia
  
• Sputum production
• Increased WBC count

You should be considering VAP. Use of the Clinical Pulmonary Infection Score can be very useful in guiding your approach to the patient with possible VAP.



A score of greater than or equal to 6 is suggestive of VAP. You should obtain samples from the LOWER respiratory tract -- not ET aspirates. There is a study suggesting ET aspirate is acceptable, but patients with Pseudomonas and MRSA were excluded as were many other patients. Samples may be obtained from either direct visualization with BAL or blind BAL, ideally before antibiotics, but antibiotics should not be significantly delayed.

Prevention:

• elevation of the head of the bed
• daily sedation vacations or even awake ventilation
  
• assessment of readiness to extubate
  
  • "if you never re-intubate any patients, you are not extubating soon enough"
    
• peptic ulcer disease prophylaxis
• deep venous thrombosis prophylaxis
• orogastric feeding as opposed to nasogastric
  
  • use of feeds in general is associated with less colonization

Treatment:

• Initiate good empiric therapy based on local hospital epidemiology
  
  • Piperacillin-Tazobactam PLUS ciprofloxacin is suggested @ our site
  • Vancomycin if high suspicion for MRSA
    
    • NB: The vancomycin vs. linezolid debate discussed here
      
• De-escalate approrpiately -- Tailor to cultures, CPIS less than 6 @ 72h consider early discontinuation
• Duration: Treat for 8 days if clinically improved, CPIS less than 6, 15 days if not improved or if Pseudomonas or MRSA (JAMA trial here)

Interesting article on VAT -- a proposed precursor to VAP is available here.