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