Associated Pneumonia

Ensure elevation of the head of the bed is 30 to 45 degrees for all mechanically ventilated patients. Minimize duration of mechanical ventilation by minimizing sedative administration (including daily sedation holidays ) and/or using protocol-based weaning. 

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Prevention of Hospital-Acquired and Ventilator-Associated Pneumonia... 

The patient was admitted to the hospital with a presumptive diagnosis of health care-associated pneumonia (based on the recent hospitalization). He received intravenous hydration with normal saline, 5 L oxygen via face mask, an insulin infusion to control his glucose, and empirical antimicrobial therapy with piperacillin-tazobactam 2.25 g intravenously every 6 hours and vancomycin 1 g intravenously every 24 hours. All other medications are continued with the exception of the diabetes medications. 

List the common pathogens that cause community-acquired pneumonia, aspiration pneumonia, ventilator-associated pneumonia (early versus late onset), and health care-associated pneumonia. 

Recognize the signs and symptoms associated with community-acquired pneumonia and ventilator-associated pneumonia. 

Empirical selection of antimicrobial therapy for ventilator-associated, health care-associated, and hospital-associated pneumonia is broad spectrum however, once culture and susceptibility information are available, the therapy should be narrowed (deescalation) to cover the identified pathogen(s). 

Pneumonia is inflammation of the lung with consolidation. The cause of the inflammation is infection, which can result from a wide range of organisms. There are five classifications of pneumonia community-acquired, aspiration, hospital-acquired, ventilator-associated, and health care-associated. Patients who develop pneumonia in the outpatient setting and have not been in any health care facilities, which include wound care and hemodialysis clinics, have community-acquired pneumonia (CAP). Aspiration is of either oropharyngeal or gastrointestinal contents. Hospital-acquired pneumonia (HAP) is defined as pneumonia that occurs 48 hours or more after admission.1,2 Ventilator-associated pneumonia (VAP) requires endotracheal intubation for at least 48 to 72 hours before the onset of... 

Hugonnet S, Eggimann P, Borst F, et al. Impact of ventilator-associated pneumonia on resource utilization and patient outcome. Infect Control Hosp Epidemiol 2004 25 1090-1096. 

Luna CM, Blanzaco D, Niederman MS, et al. Resolution of ventilator-associated pneumonia Prospective evaluation of the clinical pulmonary infection score as an early clinical predictor of outcome. Crit Care Med 2003 31 676-682. 

Niederman MS, Craven DE. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am ] Respir Crit Care Med 2005 171 388-416. 

Treatment for septic patients with hospital-acquired, ventilator-acquired, and health care-associated pneumonia is dependent on risk factors for multi-drug resistant (MDR) organisms (Fig. 79-2). Recommended treatment for patients with no MDR risk factors are third-generation cephalosporins, fluoroquinolones, ampicillin-sulbactam, or ertapenem (see Table 79-3).35 Recommended treatment for patients with MDR risk factors are P-lactam/p-lactamase inhibitors (piperacillin-tazobactam), antipseudomonal cephalosporin, or carbapenem, plus an aminoglycoside, plus vancomycin or linezolid (see Table 79-3).35 If an aminoglycoside is undesirable, a antipseudomonal fluoroquinolone may be utilized with a P-lactam/p-lactamase inhibitor. 

Prevent Ventilator-Associated Pneumonia... by implementing a series of interdependent, scientifically grounded steps... 

Bassetti M, Righi E, Fasce R, Molinari MR Rosso R, Di Biagio A, Mussap M, Pallavicini FB, Viscoli C. (2007) Efficacy of Ertapenem in the treatment of early ventilator-associated pneumonia caused by extended-spectrum beta-lactamase-producing organisms in an intensive care unit. J Antimicrob Chemother 60 433 35. 

The spectrum of respiratory tract infections (RTI) can vary from the common cold to acute or chronic bronchitis to community-acquired pneumonia to nosocomial pneumonia and aspiration pneumonia to ventilator-associated pneumonia to chronic pneumonia (in cystic fibrosis, histoplasmosis, tuberculosis, etc.). Important complications are lung abscess and pleural empyema that will often need drainage and prolonged antimicrobial treatment (>6 weeks). 

Cook D (2000) Ventilator-associated pneumonia perspectives on the burden illness. Intensive Care Med 26(S1) 31-37... 

Kollef MH (2000) Ventilator-associated pneumonia the importance of initial empiric antibiotic selection. Infect Med 17 278-283... 

Selective decontamination of the gastrointestinal tract was conceptualised with a view to preventing nosocomial infection (mainly due to enterobacteriaciae), specifically ventilator-associated pneumonia, in intensive care units. Protocols typically included the prescription of an intravenous cephalosporin with good activity against such Gram-negative pathogens (e.g. cefotaxime) with co-prescribed, poorly... 

Gorman SP, McGovern JG, Woolfson AD, et al. The concomitant development of poly(vinyl chloridej-related biofilm and antimicrobial resistance in relation to ventilator-associated pneumonia. Biomaterials 2001 22(20) 2741-2747. 

Kollef et al. conducted a single switch study where they treated patients in a cardiothoracic intensive care unit empirically for 6 months with ceftazidime and then in the second 6-month period, treated patients with ciprofloxacin. They showed a significant reduction in ventilator-associated pneumonia (VAP), mostly due to a decrease in the number of patients infected with resistant Gram-negative bacteria. This study did not employ true rotation in that a second 6-month rotation of each therapy was not conducted and, as outlined above, did not meet most of the criteria for an ideal rotation program. 

Kollef, M.H. Vlasnik, J. Sharpless, L. Pasque, C. Murphy, D. Fraser, V. Schedule changes of antibiotic classes A strategy to decrease the incidence of ventilator associated pneumonia. Am. J. Respir. Crit. Care Med. 1997, i56(4 Pt. 1), 1040 1048. 

Torres A, El-Ebiary M, Padro L, et al. Validation of different techniques for the diagnosis of ventilator-associated pneumonia. Am J Crit Care Med 1994 149 324-331. 

Cook DJ, Brun-Buisson C, Guyatt GH, et al. Evaluation of new diagnostic technologies Bronchoalveolar lavage and the diagnosis of ventilator associated pneumonia. Crit Care Med 1994 22 1314-1322. 

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