Guideline sources The following summarized guidelines for the evaluation and management of ventilator- associated pneumonia (VAP) are prepared by our editorial team based on guidelines from the Infectious Diseases Society of America (IDSA/ATS 2016). 1 Calculator Calculator Clinical Pulmonary Infection Sco RAPID score for pleural infection Guidelines 1. Diagnostic investigations Sputum cultures: consider noninvasive sampling with semiquantitative cultures to diagnose VAP, rather than invasive sampling or quantitative cultures. C 2. Medical management https://web.pathway.md/diseases/recCztPc9YOpum0gh 1/5 6/29/23, 3:25 AM Ventilator-associated pneumonia Pathway Initiation of antibiotics: use clinical criteria alone, rather than using serum procalcitonin plus clinical criteria, to decide whether or not to initiate antibiotic therapy in patients with suspected ventilator-acquired pneumonia. A Duration of treatment: complete a 7-day course of antimicrobial therapy, rather than a longer duration, for patients with VAP. A Antibiotic dosing: consider determining antibiotic dosing using pharmacokinetic/pharmacodynamic data, rather than the manufacturer's prescribing information for patients with VAP. C Empiric antibiotic therapy: Administer empiric antimicrobials with coverage for S. aureus, P. aeruginosa, and other gram-negative bacilli. B Consider one of the following regimens (doses may need to be modified for patients with hepatic or renal dysfunction): piperacillin/tazobactam 4.5 g IV q6h cefepime 2 g IV q8h levofloxacin 750 mg IV daily imipenem 500 mg IV q6h meropenem 1 g IV q8h. C Empiric MRSA coverage: Consider including an agent active against MRSA as part of the empiric treatment regimen in the following situations: patients with risk factor(s) for antimicrobial resistance patients being treated in units where > 10%-20% of S. aureus isolates are methicillin resistant patients in units where the prevalence of MRSA is not known. C Use one of the following regimens for empiric coverage of MRSA (doses may need to be modified for patients with hepatic or renal dysfunction): vancomycin 15 mg/kg IV q8-12h with goal to target 15-20 mg/mL trough level (consider a one-time loading dose of 25-30 mg/kg IV for severe illness) linezolid 600 mg IV q12h. A Empiric antipseudomonal coverage: Consider using 2 antipseudomonal antibiotics from different classes for the empiric treatment of suspected VAP in the following situations: patient with risk factor(s) for antimicrobial resistance units where > 10% of gram-negative isolates are resistant to an agent being considered for monotherapy units where local antimicrobial susceptibility rates are not available. C Aminoglycosides: consider avoiding aminoglycosides if alternative agents with adequate gram-negative activity are available in patients with suspected VAP. D Colistin: consider avoiding colistin if alternative agents with adequate gram-negative activity are available to treat suspected VAP. D https://web.pathway.md/diseases/recCztPc9YOpum0gh 2/5 6/29/23, 3:25 AM Ventilator-associated pneumonia Pathway 3. Specific circumstances Patients with VAP due to carbapenem-resistant pathogens: Administer intravenous polymixins such as colistin or polymyxin B, in patients with hospital- acquired pneumonia/ventillator- asscociated pneumonia caused by a carbapenem-resistant pathogen that is sensitive only to polymyxins. A Consider administering adjunctive inhaled colistin. C Patients with VAP due to MRSA: treat VAP due to MRSA with either vancomycin or linezolid, rather than other antibiotics or antibiotic combinations. A Patients with VAP due to P. aeruginosa: ch an antibiotic for definitive therapy based upon the results of antimicrobial susceptibility testing for patients with VAP due to P. aeruginosa. B Patients with VAP due to ESBL organisms: choose an antibiotic for definitive therapy based upon the results of antimicrobial susceptibility testing and patient-specific factors for patients with VAP due to extended-spectrum beta lactamase-producing gram-negative bacilli. B Clinical findings Past medical history Vital signs Mechanical ventilation Hypoxemia Prolonged mechanical ventilation body temperature Lab findings Respiratory exam Respiratory alkalosis Purulent endotracheal secretions Microbiological findings BAL neutrophils Hematological findings BAL bacterial culture leukocyte count bronchial aspirate bacterial culture Imaging findings Air bronchogram Air bronchograms Pulmonary infiltrates Silhouette sign Single air bronchogram Likelihood Ratios Pertinent positives The following findings increase the probability of ventilator-associated pneumonia in adults. 1 Finding LR+ Value Positive bronchial aspirate bacterial culture (> 10 CFU/mL) 9.6 https://web.pathway.md/diseases/recCztPc9YOpum0gh 3/5 6/29/23, 3:25 AM Ventilator-associated pneumonia Pathway Presence of air bronchogram 3.8 Presence of all 4 findings of ventilator-associated pneumonia* 2.5 (1.3-4.8) Presence of air bronchograms 2.0 (1.3-2.9) new radiographic infiltrate, fever, leukocytosis, and purulent sputum Show 5 more Pertinent negatives The following findings decrease the probability of ventilator-associated pneumonia in adults. 1 Finding LR- Value Absence of all 4 findings of ventilator-associated pneumonia* 0.06 (0-0.87) Absence of air bronchograms 0.29 (0.11-0.73) Negative bronchial aspirate bacterial culture ( 10 CFU/mL) 0.4 Absence of purulent endotracheal secretions 0.6 new radiographic infiltrate, fever, leukocytosis, and purulent sputum Show 5 more Studies 2022 iDIAPASON In adult patients with P. aeruginosa ventilator-associated pneumonia, short-duration therapy was noninferior to long-duration therapy with respect to the composite outcome of death and recurrence in the ICU at day 90. Adrien Bougl et al. Intensive Care Med. 2022 Jul. 2022 GRACE-VAP In patients with ventilator-associated pneumonia in the ICU, Gram stain-guided antibiotic therapy was noninferior to guideline-based antibiotic therapy with respect to clinical response. Jumpei Yoshimura et al. JAMA Netw Open. 2022 Apr 1. Show 1 more References 1. Kalil AC, Metersky ML, Klompas M et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016 Sep 1;63 5):e61-e111. Open 2. Klompas M. Does this patient have ventilator-associated pneumonia?. JAMA. 2007 Apr 11;297 14 1583 93. Open https://web.pathway.md/diseases/recCztPc9YOpum0gh 4/5 6/29/23, 3:25 AM Ventilator-associated pneumonia Pathway 3. Bruno Fran ois, Alain Cariou, Rapha l Clere-Jehl et al. Prevention of Early Ventilator-Associated Pneumonia after Cardiac Arrest. N Engl J Med. 2019 Nov 7;381 19 1831 1842. Open 4. Carolina A M Schurink, Christianne A Van Nieuwenhoven, Jan A Jacobs et al. Clinical pulmonary infection score for ventilator-associated pneumonia: accuracy and inter-observer variability. Intensive Care Med. 2004 Feb;30 2 217 224. Open 5. Jumpei Yoshimura, Kazuma Yamakawa, Yoshinori Ohta et al. Effect of Gram Stain-Guided Initial Antibiotic Therapy on Clinical Response in Patients With Ventilator-Associated Pneumonia: The GRACE VAP Randomized Clinical Trial. JAMA Netw Open. 2022 Apr 1;5 4):e226136. Open 6. Adrien Bougl , Sophie Tuffet, Laura Federici et al. Comparison of 8 versus 15 days of antibiotic therapy for Pseudomonas aeruginosa ventilator-associated pneumonia in adults: a randomized, controlled, open-label trial. Intensive Care Med. 2022 Jul;48 7 841 849. Open 7. Antoni Torres, Michael S Niederman, Jean Chastre et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia HAP /ventilator-associated pneumonia VAP of the European Respiratory Society ERS , European Society of Intensive Care Medicine ESICM , European Society of Clinical Microbiology and Infectious Diseases ESCMID and Asociaci n Latinoamericana del T rax ALAT . Eur Respir J. 2017 Sep 10;50 3 1700582. Open https://web.pathway.md/diseases/recCztPc9YOpum0gh 5/5