VENTILATOR ASSOCIATED PNEUMONIA
Erin Martinko
Created on July 4, 2024
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Erin Martinko Duke University N664
treatment of Ventilator Associated Pneumonia (VAP)
Objectives
Monitor and Evaluate Treatment Response
Understand Source Control
Recognize the Role of Supportive Care
Implement Appropriate Antibiotic Stewardship
Understand the Principles of Empiric Antibiotic Therapy
Risk factors include age, underlying illness, immunosuppression, prolonged mechanical ventilation, and improper ventilator circuit changes.
Biofilm formation on the endotracheal tube
Impaired Host Defernses
Aspitation into the lower respiratory tract
Colonization of the oropharynx
- Significantly increases morbidity, mortality, length of hospital stay, and health care costs.
Introduction
VAP is a type of lung infection that occurs in patients on mechanical ventilation for at least 48 hours.
Empiric Antibiotic Therapy
Consider patient factors such as prior antibiotic use, allergy history, and risk of multidrug-resistant organisms.
Use local antibiogram data to guide your selection
Antibiotics should cover common pathogens--> gram--negative bacilli and staph. aureus
Iniatiate empric antibiotics promptly based on clinical suspiction
EMPIRIC ANTIBIOTIC THERAPY
QUESTION 1
- Avoid unnessary use of broad-spectrum antibiotics.
- Follow local guidelines and protocols for antibiotic use.
- Typically, 7-8 days of antibiotic therapy is sufficient for most patients with VAP.
- Longer durations may be needed for patients with complicated infections or slow clinical response.
- Adjust antibiotics based on culture and sensitivity results to target specific pathogens.
- De-escalation helps reduce the risk of antibiotic resistance and adverse effects.
Antibiotic Stewardship
Strategies to prevent antibiotic resistance
Duration of therapy
De-escalation based on culture results
ANTIBIOTIC STEWARDSHIP
Question 2
- Provide adequate nutrition to support immune function and recovery.
- Consider enteral feeding as the preferred method of nutritional support.
- Manage fluid balance carefully to avoid fluid overload and pulmonary edema.
- Use diuretics if necessary to maintain euvolemia
- Ensure patients receive appropriate oxygen therapy to maintain adequate oxygen saturation levels.
- Adjust ventilator settings to optimize oxygen delivery and minimize lung injury.
Nutritional Support
Fluid Management
Adequate Oxygenation
Supportive Care
SUPPORTIVE CARE
Question 3
- Replace the ET tube if there is suspicion of biofilm formation or persistent infection.
- Removal may be necessary if the patient is ready for extubation.
- Ensure proper placement and securement of endotracheal tubes.
- Consider subglottic suctioning to remove secretions about the cuff.
- Effective source control is crucial for resolving infection and preventing recurrence.
When to Consider Removing/Replacing the ET Tube
Management of Endotracheal Tubes
Importance of Source Control
Source Control
SOURCE CONTROL
QUESTION 4
- Consider patient's clinical improvement, labortory findings, and radiographic changes.
- Adjust treatment based on overall clinical assessment.
- Monitor vital signs, including temperature and oxygen saturation.
- Check white blood cell count and assess for clinical signs of infection resolution.
- Follow up with chest x-ray to evaluate radiologic improvement
- Reassess respiratory cultures to confirm clearance of the pathogen.
- Adjust antibiotics if there is persistence of infection.
Monitoring and Followup
Criteria for Assessing Response
Microbiological Parameters: Culture Results
Clinical Parameters
Fever, WBC count, Oxygenation, Radiologic Improvement
MONITORING AND FOLLOW-UP
QUESTION %
- American Thoracic Society & Infectious Diseases Society of America. (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(4), 388–416. https://doi.org/10.1164/rccm.200405-644st
- Chastre, J., & Fagon, J.-Y. (2002a). Ventilator-associated pneumonia. American Journal of Respiratory and Critical Care Medicine, 165(7), 867–903. https://doi.org/10.1164/ajrccm.165.7.2105078
- Kalil, A. C., Metersky, M. L., Klompas, M., Muscedere, J., Sweeney, D. A., Palmer, L. B., Napolitano, L. M., O'Grady, N. P., Bartlett, J. G., Carratalà, J., El Solh, A. A., Ewig, S., Fey, P. D., File, T. M., Restrepo, M. I., Roberts, J. A., Waterer, G. W., Cruse, P., Knight, S. L., & Brozek, J. L. (2016a). 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. Clinical Infectious Diseases, 63(5), e61–e111. https://doi.org/10.1093/cid/ciw353
- Kollef, M. H., & Micek, S. T. (2005). Strategies to prevent antimicrobial resistance in the intensive care unit. Critical Care Medicine, 33(8), 1845–1853. https://doi.org/10.1097/01.ccm.0000171849.04952.79
- Mumtaz, H., Saqib, M., Khan, W., Ismail, S. M., Sohail, H., Muneeb, M., & Sheikh, S. S. (2023). Ventilator associated pneumonia in intensive care unit patients: A systematic review. Annals of Medicine & Surgery, 85(6), 2932–2939. https://doi.org/10.1097/ms9.0000000000000836
- Tamma, P. D., Avdic, E., Li, D. X., Dzintars, K., & Cosgrove, S. E. (2017). Association of adverse events with antibiotic use in hospitalized patients. JAMA Internal Medicine, 177(9), 1308. https://doi.org/10.1001/jamainternmed.2017.1938
References
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