Treatment of Ventilator-associated Pneumonia with a Risk Factor for Antimicrobial Resistance

In mechanically ventilated patients, certain clinical circumstances substantially raise the likelihood of infection with antimicrobial-resistant organisms. Identifying these risk factors at the time of VAP diagnosis is essential to guide empiric antibiotic selection.

This protocol applies when the patient has any of:

Prior intravenous antibiotic use within 90 days
Septic shock at the time of VAP
Acute respiratory distress syndrome (ARDS) preceding VAP
Five or more days of hospitalisation prior to VAP onset
Acute renal replacement therapy prior to VAP onset

Treatment approach — partial overview

When patients are not responding to intravenous antibiotics alone, adjunctive inhaled antibiotic therapy may be considered as a treatment of last resort alongside the systemic regimen. The complete selection criteria, agent choices, and clinical conditions governing their use are detailed in the full protocol.

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References

We suggest including an agent active against MRSA for the empiric treatment of suspected VAP only in patients with any of the following: a risk factor for antimicrobial resistance (Table 2), patients being treated in units where >10%–20% of S. aureus isolates are methicillin resistant, and patients in units where the prevalence of MRSA is not known (weak recommendation, very low-quality evidence).
For patients with VAP due to gram-negative bacilli that are susceptible to only aminoglycosides or polymyxins (colistin or polymyxin B), we suggest both inhaled and systemic antibiotics, rather than systemic antibiotics alone (weak recommendation, very low-quality evidence).
It is reasonable to consider adjunctive inhaled antibiotic therapy as a treatment of last resort for patients who are not responding to intravenous antibiotics alone, whether the infecting organism is or is not MDR.

DOI: 10.1093/cid/ciw353

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