Management of VAP Caused by Multidrug-Resistant Pathogens
Management of VAP Caused by Multidrug-Resistant Pathogens
Ventilator-associated pneumonia (VAP) due to multidrug-resistant (MDR) pathogens is a leading healthcare-associated infection in mechanically ventilated patients. The incidence of VAP due to MDR pathogens has increased significantly in the last decade. Risk factors for VAP due to MDR organisms include advanced age, immunosuppression, broad-spectrum antibiotic exposure, increased severity of illness, previous hospitalization or residence in a chronic care facility and prolonged duration of invasive mechanical ventilation. Methicillin-resistant Staphlococcus aureus and several different species of Gram-negative bacteria can cause MDR VAP. Especially difficult Gram-negative bacteria include Pseudomonas aeruginosa, Acinetobacter baumannii, carbapenemase-producing Enterobacteraciae and extended-spectrum β-lactamase producing bacteria. Proper management includes selecting appropriate antibiotics, optimizing dosing and using timely de-escalation based on antibimicrobial sensitivity data. Evidence-based strategies to prevent VAP that incorporate multidisciplinary staff education and collaboration are essential to reduce the burden of this disease and associated healthcare costs.
Ventilator-associated pneumonia (VAP), defined as a pneumonia that occurs 48 h after intubation, is the most frequently occurring healthcareassociated infection in mechanically ventilated patients. Incidence rates have been reported to range from 8 to 28%, with 10–20% of mechanically ventilated patients at risk for developing VAP. Recent studies have shown lower rates of VAP over the past decade. This has been attributed to improved prevention strategies and widespread VAP prevention programs. Incremental healthcare spending due to VAP ranges from US$20,000 to 40,000. Morbidity due to VAP was described in a study of 99 hospitalized intensive care unit (ICU) patients who received long-term mechanical ventilation and survived for at least 1 year after hospital discharge. These patients demonstrated a high rate of readmissions and discharges to various healthcare facilities. Additionally, they demonstrated a poor functional status and high degree of healthcare consumption, as only 9% had no dependency and the cost per survivor was US$3.4 million.
Most cases of VAP occur within 10 days of mechanical ventilation. In contrast to early-onset VAP, late-onset VAP occurs after 5 days of ventilation and is most commonly caused by methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant (MDR) Gram-negative pathogens. Multidrug resistance is defined as resistance to three or more antibiotic classes. The emergence of MDR pathogens over the past decade and the associated negative impact on patient outcomes has been well documented. In this review, the authors focus on the most common MDR pathogens causing VAP and outline preventative and treatment strategies to reduce mortality and improve patient outcomes.
Abstract and Introduction
Abstract
Ventilator-associated pneumonia (VAP) due to multidrug-resistant (MDR) pathogens is a leading healthcare-associated infection in mechanically ventilated patients. The incidence of VAP due to MDR pathogens has increased significantly in the last decade. Risk factors for VAP due to MDR organisms include advanced age, immunosuppression, broad-spectrum antibiotic exposure, increased severity of illness, previous hospitalization or residence in a chronic care facility and prolonged duration of invasive mechanical ventilation. Methicillin-resistant Staphlococcus aureus and several different species of Gram-negative bacteria can cause MDR VAP. Especially difficult Gram-negative bacteria include Pseudomonas aeruginosa, Acinetobacter baumannii, carbapenemase-producing Enterobacteraciae and extended-spectrum β-lactamase producing bacteria. Proper management includes selecting appropriate antibiotics, optimizing dosing and using timely de-escalation based on antibimicrobial sensitivity data. Evidence-based strategies to prevent VAP that incorporate multidisciplinary staff education and collaboration are essential to reduce the burden of this disease and associated healthcare costs.
Introduction
Ventilator-associated pneumonia (VAP), defined as a pneumonia that occurs 48 h after intubation, is the most frequently occurring healthcareassociated infection in mechanically ventilated patients. Incidence rates have been reported to range from 8 to 28%, with 10–20% of mechanically ventilated patients at risk for developing VAP. Recent studies have shown lower rates of VAP over the past decade. This has been attributed to improved prevention strategies and widespread VAP prevention programs. Incremental healthcare spending due to VAP ranges from US$20,000 to 40,000. Morbidity due to VAP was described in a study of 99 hospitalized intensive care unit (ICU) patients who received long-term mechanical ventilation and survived for at least 1 year after hospital discharge. These patients demonstrated a high rate of readmissions and discharges to various healthcare facilities. Additionally, they demonstrated a poor functional status and high degree of healthcare consumption, as only 9% had no dependency and the cost per survivor was US$3.4 million.
Most cases of VAP occur within 10 days of mechanical ventilation. In contrast to early-onset VAP, late-onset VAP occurs after 5 days of ventilation and is most commonly caused by methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant (MDR) Gram-negative pathogens. Multidrug resistance is defined as resistance to three or more antibiotic classes. The emergence of MDR pathogens over the past decade and the associated negative impact on patient outcomes has been well documented. In this review, the authors focus on the most common MDR pathogens causing VAP and outline preventative and treatment strategies to reduce mortality and improve patient outcomes.