Ventilator-associated pneumonia (VAP) is one of the most common causes of infection in intensive care unit (ICU) patients. Efforts to prevent VAP have focused on both pharmacologic and nonpharmacologic strategies. Two of the more controversial pharmacologic approaches included selective decontamination of the digestive tract (SDD) and decontamination of the oropharynx using topical antimicrobials or antiseptics including chlorhexidine (CHX). Additionally, avoidance of pharmacotherapy-related risk factors is hypothesized to reduce VAP rates. Successful treatment of VAP is becoming increasingly difficult in the era of antibiotic resistance. Utilization of local antibiograms, implementation of standardized treatment pathways, and optimization of pharmacodynamic-based dosing offer methods to improve empiric therapy selections. De-escalation of therapy should be a constant focus in an attempt to reduce overall antibiotic consumption and the selection pressure on ICU flora, thus minimizing the development and spread of antimicrobial resistance in the ICU.
StoutenbeekCPvan SaeneHKFMirandaDR. The effect of selective decontamination of the digestive tract on colonization and infection rate in multiple trauma patients. Intensive Care Med. 1984;10(4):185–192.
2.
Van NieuwenhovenCABuskensEvan TielFH. Relationship between methodologic trial quality and the effects of selective digestive decontamination on pneumonia and mortality in critically ill patients. JAMA. 2001;286(3):335–340.
3.
de JongeESchultzMJSpanjaardL. Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomized controlled trial. Lancet. 2003;362(9389):1011–1016.
4.
KruegerWALenhartFPNeeserG. Influence of combined intravenous and topical antibiotic prophylaxis on the incidence of infections, organ dysfunctions, and mortality in critically ill surgical patients. Am J Respir Crit Care Med. 2002;166(8):1029–1037.
5.
de la CalMACerdáEGarcía-HierroP. Survival benefit in critically ill burned patients receiving selective decontamination of the digestive tract: a randomized, placebo-controlled, double-blind trial. Ann Surg. 2005;241(3):424–430.
6.
SilvestriLvan SaeneHKFCasarinA. Impact of selective decontamination of the digestive tract on carriage and infection due to gram-negative and gram-positive bacteria: a systematic review of randomized controlled trials. Anaesth Intensive Care. 2008;36(3):324–338.
7.
LingnauWBergerJJavorskyF. Changing bacterial ecology during a five-year period of selective intestinal decontamination. J Hosp Infect. 1998;39(3):195–206.
8.
VerwaestCVerhaegenJFerdinandeP. Randomized controlled trial of selective digestive decontamination in 600 mechanically ventilated patients in a multidisciplinary intensive care unit. Crit Care Med. 1997;25(1):63–71.
9.
HammondJMJPotgieterPDSaundersGL. Double-blind study of selective decontamination of the digestive tract in intensive care. Lancet. 1992;340(8810):5–9.
10.
ChanEYRuestAMeadeMO. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ. 2007;334(7599):889–900.
11.
Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388–416.
12.
CoffinSEKlompasMClassenD. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(suppl 1):S31–S40.
13.
de SmetAMGAKluytmansJAJWCooperBS. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med. 2009;360(1):20–31.
14.
SenolGKirakliCHalilcolarH. In vitro antibacterial activities of oral care products against ventilator-associated pneumonia pathogens. Am J Infect Control. 2007;35(8):531–535.
15.
DeRisoAJLadowskiJSDillonTA. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory tract infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest. 1996;109(6):1556–1561.
16.
SegersPSpeekenbrinkRGHvan OgtropML. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: a randomized controlled trial. JAMA. 2006;296(20):2460–2466.
17.
FourrierFPottier-CauEBoutignyH. Effects of dental plaque antiseptic decontamination on bacterial colonization and nosocomial infections in critically ill patients. Intensive Care Med. 2000;26(9):1239–1247.
18.
FourrierFDuboisDPronnierP. Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study. Crit Care Med. 2005;33(8):1728–1735.
19.
PanchabhiaTSDangayachNSKrishnanA. Oropharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in critically ill patients: an open-label randomized trial with 0.01% potassium permanganate as control. Chest. 2009;135(5):1150–1156.
20.
KoemanMvan der VenAHakE. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med. 2006;173(12):1348–1355.
21.
TantipongHMorkcharonpongCJaiyindeeS. Randomized controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infect Control Hosp Epidemiol. 2008;29(2):131–136.
22.
KolaAGastmeierP. Efficacy of oral chlorhexidine in preventing lower respiratory tract infections. Meta-analysis of randomized controlled trials. J Hosp Infect. 2007;66(3):207–216.
23.
ChlebickiMJSafdarN. Topical chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. Crit Care Med. 2007;35(2):595–602.
24.
GirardTDKressJPFuchsBD. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomized controlled trial. Lancet. 2008;371(9607):126–134.
25.
BrookADAhrensTSSchaiffR. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med. 1999;27(12):2609–2615.
26.
KressJPPohlmanASO’ConnorMF. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20):1471–1477.
27.
QuenotJPLadoireSDevoucouxF. Effect of a nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia. Crit Care Med. 2007;35(9):2031–2036.
28.
JacobiJFraserGLCoursinDB. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30(1):119–141.
29.
BontenMJBergmansDCAmbergenAW. Risk factors for pneumonia and colonization of the respiratory tract and stomach in mechanically ventilated ICU patients. Am J Respir Crit Care Med. 1996;154(5):1339–1346.
30.
BontenMJGaillardCAde LeeuwPW. Role of colonization of the upper intestinal tract in the pathogenesis of ventilator-associated pneumonia. Clin Infect Dis. 1997;24(3):309–319.
31.
MarkowiczPWolffMDjedainiK. Multicenter prospective study of ventilator-associated pneumonia during acute respiratory distress syndrome. Am J Respir Crit Care Med. 2000;161(6):1942–1948.
32.
CookDGuyattGMarshallJ. A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. N Engl J Med. 1998;338(12):197–207.
33.
GulmezSEHolmAFrederiksenH. Use of proton pump inhibitors and the risk of community-acquired pneumonia: a population-based case-control study. Arch Intern Med. 2007;167(9):950–955.
34.
SarkarMHennessySYangYX. Proton-pump inhibitor use and the risk for community-acquired pneumonia. Ann Intern Med. 2008;149(6):391–398.
35.
BeaulieuMWilliamsonDSiroisC. Do proton-pump inhibitors increase the risk of nosocomial pneumonia in a medical intensive care unit. J Crit Care. 2008;23(4):513–518.
36.
MianoTAReichertMGHouleTT. Nosocomial pneumonia risk and stress ulcer prophylaxis: a comparison of pantoprazole vs ranitidine in cardiothoracic surgery patients. Chest. 2009;136(2):440–447.
37.
HerzigSJHowellMDNgoLH. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA. 2009;301(20):2120–2128.
38.
KollefMHWardS. The influence of mini-BAL cultures on patient outcomes: implications for the antibiotic management of ventilator-associated pneumonia. Chest. 1998;113(2):412–420.
39.
LunaCMVujacichPNiedermanMS. Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia. Chest. 1997;111(3):676–685.
40.
Alvarez-LermaF. Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. ICU-Acquired Pneumonia Study Group. Intensive Care Med. 1996;22(5):387–394.
41.
IreguiMWardSShermanG. Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia. Chest. 2002;122(1):262–268.
42.
HeylandDKDodekPMuscedereJ. Randomized trial of combination versus monotherapy for the empiric treatment of suspected ventilator-associated pneumonia. Crit Care Med. 2008;36(3):737–744.
43.
NamiasNSamiianLNinoD. Incidence and susceptibility of pathogenic bacteria vary between intensive care units within a single hospital: implications for empiric antibiotic strategies. J Trauma. 2000;49(4):638–645.
44.
RelloJSa-BorgesMCorreaH. Variations in etiology of ventilator-associated pneumonia across four treatment sites: implications for antimicrobial prescribing practices. Am J Respir Crit Care Med. 1999;160(2):608–613.
45.
BeardsleyJRWilliamsonJCJohnsonJW. Using local microbiologic data to develop institution-specific guidelines for the treatment of hospital-acquired pneumonia. Chest. 2006;130(3):787–793.
46.
IbrahimEHWardSShermanG. Experience with a clinical guideline for the treatment of ventilator-associated pneumonia. Crit Care Med. 2001;29(6):1109–1115.
47.
WoodGCMuellerEWCroceMA. Evaluation of a clinical pathway for ventilator-associated pneumonia: changes in bacterial flora and the adequacy of empiric antibiotics over a three-year period. Surg Infect. 2005;6(2):203–213.
48.
LanchesterJWLawrenceKRFongJJ. Impact of an institution-specific hospital-acquired pneumonia protocol on the appropriateness of antibiotic therapy and patient outcomes. Pharmacotherapy. 2008;28(7):852–862.
49.
DellitTHChanJDSkerrettSJ. Development of a guideline for the management of ventilator-associated pneumonia based on local microbiologic findings and impact of the guideline on antimicrobial use practices. Infect Control Hosp Epidemiol. 2008;29(6):525–533.
50.
BhatSVPelegAYLodiseTPJr. Failure of current cefepime breakpoints to predict clinical outcomes of bacteremia caused by gram-negative organisms. Antimicrob Agents Chemother. 2007;51(12):4390–4395.
51.
TamVHGamezEAWestonJS. Outcomes of bacteremia due to Pseudomonas aeruginosa with reduced susceptibility to piperacillin-tazobactam: implications on the appropriateness of the resistance breakpoint. Clin Infect Dis. 2008;46(6):862–867.
52.
NicasioAMArianoREZelenitskySA. Population pharmacokinetics of high-dose, prolonged-infusion cefepime in adult critically ill patients with ventilator-associated pneumonia. Antimicrob Agents Chemother. 2009;53(4):1476–1481.
53.
NicasioAMEagyeKJNicolauDP. Pharmacodynamic-based clinical pathway for empiric antibiotic choice in patients with ventilator-associated pneumonia. J Crit Care. 2009. In press.
54.
LodiseTPJrLomaestroBDrusanoGL. Piperacillin-tazobactam for Pseudomonas aeruginosa infection: clinical implications of an extended-infusion dosing strategy. Clin Infect Dis. 2007;44(3):357–363.
55.
ChastreJWunderinkRProkocimerP. Efficacy and safety of intravenous infusion of doripenem versus imipenem in ventilator-associated pneumonia: A multicenter, randomized study. Crit Care Med. 2008;36(4):1089–1096.
56.
RelloJVidaurLSandiumengeA. De-escalation therapy in ventilator-associated pneumonia. Crit Care Med. 2004;32(11):2183–2190.
57.
EachempatiSRHydoLJShouJ. Does de-escalation of antibiotic therapy for ventilator-associated pneumonia affect the likelihood of recurrent pneumonia or mortality in critically ill surgical patients?. J Trauma. 2009;66(5):1343–1348.
58.
MicekSTWardSFraserVJ. A randomized controlled trial of an antibiotic discontinuation policy for clinically suspected ventilator-associated pneumonia. Chest. 2004;125(5):1791–1799.
