Background: Ventilator-associated pneumonia (VAP) is the most frequent intensive care unit
(ICU)-acquired infection among patients receiving mechanical ventilation. Failure to initiate
appropriate and adequate therapy (i.e., the etiologic organism is sensitive to the therapeutic
agent, the dose is optimal, and the route of administration is correct) promptly in patients
with VAP has been associated consistently with higher mortality rates. However, effective
antimicrobial therapy for patients with true VAP can be achieved while avoiding excessive
antibiotic use and the emergence of multidrug-resistant strains in the ICU.
Method: Review of the pertinent English-language literature.
Results: Antimicrobial therapy for patients with VAP should follow a two-stage process.
The first stage is identifying true pneumonia rapidly and starting therapy with an empirical
regimen that is likely to be appropriate. In general, this requires using broad-spectrum antibiotics
in all patients in whom there is a possibility that the etiologic pathogen could be
difficult to treat (e.g., multi-drug-resistant pathogen). The second stage focuses on trying to
achieve this objective without overusing and abusing antibiotics and combines a number of
steps, such as stopping therapy in patients with a low probability of the disease, streamlining
treatment once the etiologic agent is known, switching to monotherapy after three to five
days, and shortening the duration of therapy to seven or eight days, as dictated by the patient's
clinical response to therapy and information about the bacteriology of the infection.
Conclusion: Although such a strategy seems a logical way to manage patients with VAP,
data are still needed to determine how best to achieve this process.
