Theme Issue Editorial
Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Diagnosis and treatment

https://doi.org/10.1016/j.jcrc.2007.12.008Get rights and content

Abstract

Background

Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in ventilated critically ill patients. Despite a large amount of research evidence, the optimal diagnostic and treatment strategies for VAP remain controversial.

Purpose

The aim of this study was to develop evidence-based clinical practice guidelines for the diagnosis and treatment of VAP. Data sources include Medline, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Database of Systematic Reviews and Register of Controlled Trials.

Study Selection

The authors systematically searched for all relevant randomized controlled trials and systematic reviews on the diagnosis and treatment of VAP in mechanically ventilated adults that were published from 1980 to October 1, 2006.

Data Extraction

Independently and in duplicate, the panel critically appraised each published trial. The effect size, confidence intervals, and homogeneity of the results were scored using predefined definitions. The full guideline development panel arrived at a consensus for scores on safety, feasibility, and economic issues.

Levels of Evidence

Based on the scores for each topic, the following statements of recommendation were used: recommend, consider, do not recommend, and no recommendation because of insufficient or conflicting evidence.

Data Synthesis

For the diagnosis of VAP in immunocompetent patients, we recommend that endotracheal aspirates with nonquantitative cultures be used as the initial diagnostic strategy. When there is a suspicion of VAP, we recommend empiric antimicrobial therapy (in contrast to delayed or culture directed therapy) and appropriate single agent antimicrobial therapy for each potential pathogen as empiric therapy for VAP. Choice of antibiotics should be based on patient factors and local resistance patterns. We recommend that an antibiotic discontinuation strategy be used in patients who are treated of suspected VAP. For patients who receive adequate initial antibiotic therapy, we recommend 8 days of antibiotic therapy. We do not recommend nebulized endotracheal tobramycin or intratracheal instillation of tobramycin for the treatment of VAP.

Conclusion

We present evidence-based recommendations for the diagnosis and treatment of VAP. Implementation of these recommendations into clinical practice may lessen the morbidity and mortality of patients who develop VAP.

Introduction

Despite efforts to prevent ventilator-associated pneumonia (VAP), this disease continues to occur frequently in critically ill patients and is associated with significant morbidity and mortality [1], [2], [3], [4], [5]. Although prevention is paramount, when VAP does occur, optimal management is important to reduce further morbidity, mortality, and health care costs. The 2 main facets of VAP management are its diagnosis and treatment.

The diagnosis of VAP is challenging [6], [7]. Bedside evaluation using clinical and radiographic criteria for the presence of VAP is neither specific nor sensitive [8]. The reference standard for the diagnosis of VAP remains the histopathologic examination and culture of lung tissue [9], [10]. However, this technique is invasive, has associated risks, and thus has not been adopted for the routine clinical diagnosis of VAP. Both invasive (bronchoscopic) and noninvasive (endotracheal aspirates) techniques to obtain samples for microbiological cultures are used in clinical practice, without consensus as to which technique is superior [11]. A recently published meta-analysis suggested that bronchoscopic techniques as compared to endotracheal aspirates have no effect on mortality but are superior for the management of antibiotic therapy for VAP [12]. In the American Thoracic Society guidelines, invasive quantitative cultures are favored over endotracheal aspirates [13]. However, these findings were not confirmed by a large recently published trial, which compared bronchoscopy and bronchoalveolar lavage to endotracheal aspirates, and found no difference in mortality, antibiotic management, or other clinical outcomes in patients without suspected or documented multidrug-resistant organisms [14].

The optimal antimicrobial agents and duration of treatment of VAP is also unclear [15]. Delays in appropriate therapy are associated with increased morbidity and mortality [16], [17], [18]. Recent trials have demonstrated that treatment duration can be safely shortened from traditional 2-week courses, that antibiotic management protocols improve outcomes, and that antibiotic discontinuation based on objective criteria reduces antibiotic use without adversely affecting clinical outcomes [19], [20], [21].

Given the volume and complexity of the published trials about VAP, comprehensive clinical practice guidelines are needed to distill and translate this knowledge on VAP prevention, diagnosis, and treatment into recommendations for action. Therefore, the Canadian Critical Care Trials Group undertook the development of an updated evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of VAP. Herein, we report our guidelines for the diagnosis and treatment of VAP. The guidelines for the prevention of VAP are also reported in this issue [22].

Section snippets

Methods

The detailed methods for creating these guidelines are reported in the companion article of guidelines for VAP prevention in this issue [22]. In brief, a multispecialty panel (N = 29) of intensivists, infectious disease physicians, respiratory therapists, pharmacists, and nurses was convened. We considered all relevant literature in the clinical context of Canadian intensive care units (ICUs), and the target audience was ICU clinicians.

To identify potentially relevant evidence, we searched 4

Results

The final summary statements and levels of evidence for each of the interventions are reported. The results are divided into diagnosis and treatment strategies. Treatment strategies are divided into initial treatment, duration of treatment, choice of antibiotic, and route of antibiotic administration. The summary of the recommendations is reported in Table 1. The semiquantitative scores for each intervention are presented in Table 2, and the agreement scores for each panel member are presented

Discussion

We have developed evidence-based clinical practice guidelines for the diagnosis and treatment of VAP. However, clinical challenges remain for critical care practitioners in spite of the extensive amount of research evidence that is available. These guidelines only incorporate high-level RCT evidence and illustrate the state of current knowledge on the diagnosis and treatment of VAP.

There is continued controversy over the optimal diagnostic strategy for the diagnosis of VAP. Approaches range

Acknowledgments

The authors thank the Canadian Critical Care Trials Group and Canadian Critical Care Society for their support of this initiative and the professional societies, which reviewed and critiqued this guideline. We are grateful to Drs Christian Brun-Buisson and Andrew Shorr for constructive criticisms on this document. This project was supported by a research grant from the Department of Medicine, Queen's University, Kingston, Ontario, and an unrestricted grant from Pfizer Canada Inc (Kirkland,

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    Ventilator-associated pneumonia guidelines committee was composed of Martin Albert, Clarence Chant, Sue Elliott, Richard Hall, Lori Hand, Rick Hodder, Carolyn Hoffman, Mike Jacka, Lynn Johnston, Jim Kutsogiannis, David Leasa, Kevin Laupland, Martin Legare, Claudio Martin, Mike Miletin, Brenda Morgan, Linda Nusdorfer, Juan Ronco, Kevin Saunders, Taz Sinuff, Derek Townsend, Louis Valiquette, Christine Weir, Karl Weiss, Dan Zuege.

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    Copyright © 2008 Elsevier Inc. All rights reserved.