Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults

Abstract

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are important causes of morbidity and mortality, with mortality rates approaching 62%. HAP and VAP are the second most common cause of nosocomial infection overall, but are the most common cause documented in the intensive care unit setting. In addition, HAP and VAP produce the highest mortality associated with nosocomial infection. As a result, evidence-based guidelines were prepared detailing the epidemiology, microbial etiology, risk factors and clinical manifestations of HAP and VAP. Furthermore, an approach based on the available data, expert opinion and current practice for the provision of care within the Canadian health care system was used to determine risk stratification schemas to enable appropriate diagnosis, antimicrobial management and nonantimicrobial management of HAP and VAP. Finally, prevention and risk-reduction strategies to reduce the risk of acquiring these infections were collated. Future initiatives to enhance more rapid diagnosis and to effect better treatment for resistant pathogens are necessary to reduce morbidity and improve survival.

Keywords: Guidelines; Hospital-acquired; Pneumonia; Ventilator-associated.

Figures

Figure 1

Breakdown of hospital-acquired pneumonia/intensive care unit (HAP/ICU) and HAP/ventilator-associated pneumonia (VAP). Information taken from references ,,,

Figure 2

Endogenous and exogenous sources of microorganisms causing hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). Adapted from references ,

Figure 3

Algorithm for determining the microbiological cause of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) using risk factors for resistance and severity of illness. MRSA Methicillin-resistant Staphylococcus aureus; MSSA Methicillin-sensitive S aureus. Data are from references ,,,–, and represent level A-2 data

Figure 4

The pathogenesis of hospital-acquired pneumonia and ventilator-associated pneumonia. Adapted from reference

Figure 5

Diagnostic algorithm for hospital-acquired pneumonia and ventilator-associated pneumonia. Please note that there is no definitive scientific evidence or expert consensus that quantitative testing produces better clinical outcomes than empirical treatment. Scientific evidence of improved specificity, supplemented by expert opinion, supports the performance of invasive tests to avoid the use of antibiotics for clinically insignificant organisms, but there is no direct evidence or consensus regarding the superiority of one invasive test over another. Factors to consider in choosing an appropriate test include sensitivity and specificity, ability to improve patient outcome, potential adverse effects, test availability and cost. CPIS Clinical pulmonary infection score; ICU Intensive care unit; PaO2 Partial pressure of oxygen in arterial blood

Figure 6

Treatment algorithm for hospital-acquired pneumona. BID Twice daily; ICU Intensive care unit; IV Intravenous; MRSA Methicillin-resistant Staphylococcus aureus; MSSA Methicillin-susceptible S aureus; q Every; po By mouth

Figure 7

Treatment algorithm for ventilator-associated pneumonia (VAP). d Day; IV Intravenous; MRSA Methicillin-resistant Staphylococcus aureus; MSSA Methicillin-sensitive S aureus; q Every