Ventilator-associated pneumonia treatment

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). 

Kofteridis DP, Alexopoulou C, Valachis A, Maraki S, Dimopoulou D, Georgopoulos D, Samonis G. Aerosolized plus intravenous colistin versus intravenous colistin alone for the treatment of ventilator-associated pneumonia a matched case-control stutfy. Clin Infect Dis 2010 51(11) 1238-44. 

Florescu DF, Qiu F, McCartan MA, Mindru C, Fey PD, Kalil AC. What is the efficacy and safety of colistin for the treatment of ventilator-associated pneumonia A systematic review and meta-regression. Clin Infect Dis 2012 54(5) 670-80. 

Torres A, Ewig S. Diagnosing ventilator-associated pneumonia. N Engl J Med 2004 350 433 35. loanas M, Cavalcanti M, Eerrer M, et al. Hospital-acquired pneumonia coverage and treatment adequacy of current guidelines. Eur Respir J 2003 22 876-882. 

Mechanieally ventilated patients are exposed to multiple devices and are at particular risk of development of ventilator-associated pneumonia (VAP), the risk of which is proportional to the duration of assisted ventilation (see Table 4). The rates of nosocomial infections may be influenced by the type of intensive care unit in which the patient undergoes treatment, with higher rates observed in surgical intensive care than in medical ICU patients (22,129,130). We examine specific devices that have been associated with NP... 

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. 

Aerosol - Several serious adverse events occurred in severely ill infants with life-threatening underlying diseases, many of whom required assisted ventilation. Additional reports of worsening of respiratory status, bronchospasm, pulmonary edema, hypoventilation, cyanosis, dyspnea, bacterial pneumonia, pneumothorax, apnea, atelectasis, and ventilator dependence have occurred. Sudden deterioration of respiratory function has been associated with initiation of aerosolized ribavirin use in infants. If ribavirin aerosol treatment produces sudden deterioration of respiratory function, stop treatment and reinstitute only with extreme caution, continuous monitoring, and consideration of coadministration of bronchodilators. 

In several studies, transfusion of older compared with fresh erythrocytes has been associated with increased mortality, prolonged hospitalization, intensive care treatment, mechanical ventilation, an increased risk of postoperative pneumonia, infection at any site, and multiorgan failure [21, 22 ]. However, most studies suffered from not adjusting the data for the number of units transfused. Patients who received old erythrocytes often received more cells on average than recipients of fresh erythrocytes. The amount of ceUs transfused reflects the severity of the illness, co-morbidity, and a poorer baseline prognosis [23 ]. A meta-analysis did not support the suspicion that old erythrocytes are associated with common adverse mor-bidity/mortality outcomes [24 ]. 

The factors associated with a poor prognosis in leflunomide-induced lung injury have been studied in 22 patients with rheumatoid arthritis, of whom 9 died and 13 recovered [39 ]. The patients who died tended to have pre-existing interstitial pneumonia (8/9 vs. 6/13). The loading and maintenance doses, the serum concentration of the leflunomide metabolite A771726, and the duration of treatment did not differ between the groups. The patients who died had more frequent hypoxemia and mechanical ventilation, had a high serum CRP concentration (190 vs. 100 mg/1), and had a low albumin concentration (27 versus 33 g/1). The lymphocyte count was persistently low in those who died, but recovered in those who survived. 

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