Ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) refers to pneumoniawhich occurs in people who have required mechanical ventilationthrough an endotrachealor tracheostomytube for at least 48 hours. VAP is a medical condition that results from infectionwhich floods the small, air-filled sacs(alveoli) in the lungresponsible for absorbing oxygenfrom the atmosphere. VAP is distinguished from other kinds of infectious pneumonia because of the different types of microorganismsresponsible, antibioticsused to treat, methods of diagnosis, ultimate prognosis, and effective preventivemeasures.

Symptoms and Signs

People who being mechanically ventilated are often sedated and rarely are able to communicate. As such, many of the typical symptoms of pneumonia will either be absent or unable to be obtained. The most important symptoms are fever, low body temperature, new purulentsputum, or decreasing amounts of oxygen in the blood.

Diagnosis

VAP should be suspected in any person with symptoms of VAP, increasing numbers of white blood cellson blood testing, and new shadows (infiltrates) on a chest x-ray. Blood culturesmay reveal the microorganism causing VAP.

Two strategies exist for diagnosing VAP. One strategy collects cultures from the tracheaof people with symptoms of VAP plus a new or enlarging infiltrate on chest x-ray. The other is more invasive and advocates a bronchoscopyplus bronchoalveolar lavage(BAL) for people with symptoms of VAP plus a new or enlarging infiltrate on chest x-ray. In both cases, VAP is not diagnosed when cultures are negative and another source of the symptoms is sought.

Pathophysiology

VAP primarily occurs because the endotracheal or tracheostomy tube allows free passage of bacteria into the lower segments of the lung in a person who often has underlying lung or immune problems. Bacteria travel in small dropletsboth through the endotracheal tube and around the cuff. Often, bacteria colonize the endotracheal or tracheostomy tube and are embolizedinto the lungs with each breath. Bacteria may also be brought down into the lungs with procedures such as deep suctioning or bronchoscopy.

Whether or not bacteria also travel from the sinusesor the stomach into the lungs is, as of 2005, controversial. However, spread to the lungs from the blood streamor the gutis uncommon.

Once inside the lungs, bacteria then take advantage of any deficiencies in the immune system(such as due to malnutrition or chemotherapy) and multiply. A combination of bacterial damage and consequences of the immune response lead to disruption of gas exchangewith resulting symptoms.

Microbiology

The microbiologic floraresponsible for VAP is different from that of the more common community-acquired pneumonia(CAP). In particular, viruses and fungi are uncommon causes in people who do not have underlying immune deficiencies. Though any microorganism that causes CAP can cause VAP, there are several bacteria which are particularly important causes of VAP because of their resistance to commonly used antibiotics. These bacteria are referred to as multidrug resistant(MDR).

• Pseudomonas aeruginosa is the most common MDR Gram-negativebacterium causing VAP. Pseudomonas has natural resistance to many antibiotics and has been known to acquire resistance to every antibiotic except for polymixin B. Resistance is typically acquired through upregulation or mutation of a variety of efflux pumps which pump antbiotics out of the cell. Resistance may also occur through loss of an outer membrane porin channel (OprD)
• Klebsiella pneumoniae has natural resistance to some beta-lactam antibioticssuch as ampicillin. Resistance to cephalosporinsand aztreonammay arise through induction of a plasmid-based extended spectrum beta-lactamase(ESBL) or plasmid-based ampC-type enzyme
• Serratia marcescens has an ampC genewhich can be induced by exposure to antibiotics such as cephalosporins. Thus, culture sensitivities may initially indicate appropriate treatment which fails due to bacterial response.
• Enterobacter as a group also have an inducible ampC gene. Enterobacter may also develop resistance by acquiring plasmids
• Citrobacter also has an inducible ampC gene.
• Stenotrophomonas maltophilia often colonizes people who have endotracheal tubesor tracheostomiesbut can also cause pneumonia. It is often resistant to a wide array of antibiotics but is usually sensitive to co-trimoxazole
• Acinetobacter are becoming more common and may be resistant to carbapenemssuch as imipenemand meropenem
• Burkholderia cepacia is an important organism in people with cystic fibrosis and is often resistant to multiple antibiotics
• Methicillin-resistant Staphylococcus aureus is an increasing cause of VAP. As many as fifty percent of Staphylococcus aureus isolates in the intensive care setting are resistant to methicillin. Resistance is conferred by the mecAgene.

Treatment

Treatment of VAP should be matched with a known causative bacteria. However, when VAP is first suspected, the bacteria causing infection is typically not known. Broad-spectrum antibiotics are given (empiric therapy) until the particular bacteria and its sensitivity to different antibiotics are determined.

Empiric antibiotics should take into account both the risk factors a particular individual has for resistant bacteria as well as the local prevalence of resistant microorganisms. If a person has previously had episodes of pneumonia, information may be available about prior causative bacteria.

Risk factors for MDR include ventilation for more than five days, recent hospitalization (last 90 days), residence in a nursing home, treatment in a hemodialysisclinic, and prior antibiotic use (last 90 days). Individuals with risk factors for MDR should receive empiric therapy with one of several regimens with includes vancomycinor linezolidPLUS ciprofloxacin, levofloxacin, gentamicin, amikacin, or tobramycinPLUS cefepime, ceftazidime, piperacillin/tazobactam, imipenem, or meropenem. Therapy is typically changed to a single antibiotic once the causative bacterium is known and continued for eight days as long as symptoms resolve.

People who do not have risk factors for MDR may be treated differently depending on the local incidence of MDR bacteria. Appropriate antibiotics include ceftriaxone, ciprofloxacin, levofloxacin, or ampicillin/sulbactamalone.

As of 2005, investigation into inhaled antibiotics is ongoing. Two examples, inhaled tobramycinand polymixin Bare used in certain cases but have not been proven effective in clinical trials.

Prevention

Prevention of VAP involves limiting exposure to resistant bacteria, discontinuing mechanical ventilation as soon as possible, and a variety of strategies to limit infection while intubated. Resistant bacteria are spread in much the same ways as any communicable disease. Proper hand washing, sterile techniquefor invasive procedures, and isolation of individuals with known resistant organisms are all mandatory for effective infection control. A variety of aggressive weaning protocols to limit the amount of time a person spends intubation have been proposed. One important aspect is limiting the amount of sedation that a ventilated person receives.

Several other methods for limiting VAP exist. Raising the head of the bed to at least 45 degrees results in fewer episodes of VAP. Placement of feedings tubesbeyond the pylorusof the stomachmay also result in less VAP. Administration of an oral antibiotic such as chlorhexidineis also associated with fewer episodes of VAP.

Epidemiology and prognosis

VAP occurs in up to 25% of all people who require mechanical ventilation. VAP can develop at any time during ventilation, but occurs more often in the first few days after intubation. This is because the intubation process itself contributes to the development of VAP. VAP occurring early after intubation typically involves fewer resistant organisms and is thus associated with a more favorable outcome. Because respiratory failure requiring mechanical ventilation is itself associated with a high mortality, determination of the exact contribution of VAP to mortality has been difficult. As of 2005, estimates range from 33% to 50% death in patients who develop VAP. Mortality is more likely when VAP is associated with certain microorganisms (Pseudomonas, Acinetobacter), blood stream infections, and ineffective initial antibiotics. VAP is especially common in people who have acute respiratory distress syndrome(ARDS).

See also

Pneumonia

References

American Thoracic Society and the Infectious Diseases Society of America. ATS/IDSA Guidelines: Guidelines for the management of adults with HAP, VAP, and HCAP Am J Respir Crit Care Med 2005; 171:388.

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