Updated Guidelines for Management of Hospital-Acquired/Ventilator-Associated Pneumonia

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The panel of experts were appointed by ERS, ESICM, ESCMID and ALAT. <i>Photo Credit: Barry Slaven</i>
The panel of experts were appointed by ERS, ESICM, ESCMID and ALAT. Photo Credit: Barry Slaven

Since the last update of guidelines approximately 10 years ago for managing hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), new research data and treatment options for managing these conditions have emerged. Several European medical societies convened a task force to update the guidelines, and their recommendations were reported recently in the European Respiratory Journal.

The project was led by the European Respiratory Society (ERS) and included representatives from the European Society of Intensive Care Medicine (ESICM), the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), and the Latin American Thoracic Association (ALAT), as well as other European societies. The task force panel comprised 15 experts, including 3 from the United States, and 2 methodologists.

The panel experts reviewed 109 studies from MEDLINE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systemic Reviews, and the National Health Service's Economic Evaluation Database. Using GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology to assign a level of high, moderate, low, or very low and 7 PICO (population-intervention-comparison-outcome) questions, the panel came up with a series of recommendations for diagnosis, treatment, and prevention of HAP/VAP.  

1. Use of distal vs proximal quantitative sampling in intubated patients suspected to have VAP

  • The panel recommends a lower respiratory tract sample — either a distal quantitative or a proximal quantitative or qualitative sample — to establish which initial empiric antibiotic treatment to use. (Strong recommendation, low quality of evidence.)
  • The panel suggests in stable patients with suspected VAP, prior to starting antibiotics, obtain distal quantitative samples to limit exposure of antibiotic therapy and focus on improvement of accuracy of results. (Weak recommendation, low quality of evidence.)

2. Suspicion of nosocomial pneumonia, with early onset of infection with none of the usual risk factors for multidrug-resistant (MDR) pathogens vs late-onset of infections with classic MDR risk factors

  • The panel recommends use of empiric, broad-spectrum antibiotics when treating Pseudomonas aeruginosa and extended-spectrum β-lactamase-producing organisms, as well as in settings where there is a high prevalence of Acinetobacter spp. (Strong recommendation, low quality of evidence.)
  • The panel suggests use of narrow-spectrum antibiotics such as ceftriaxone, cefotaxime, ertapenem, levofloxacin, or moxifloxacin for patients with early-onset onset HAP/VAP who are at low risk for resistance. (Weak recommendation, very low quality of evidence.)
  • The panel advises choosing antibiotic therapy based on susceptibility data when they become available. (Good practice statement.)

3. Choosing between a single antibiotic or a combination regimen when using broad-spectrum empiric therapy for HAP/VAP

  • For high-risk HAP/VAP patients, combination therapy is recommended to treat Gram-negative bacteria, with antibiotic coverage for those at risk for methicillin-resistant Staphylococcus aureus (MRSA). (Strong recommendation, moderate quality of evidence.)
  • In settings where combination therapy is started, consider changing to a single agent if results of cultures warrant; maintain combination therapy in the setting of extensive drug resistance based on sensitivity data. (Weak recommendation, low quality of evidence.)

4. Shortening duration of antibiotic therapy from 14 days to 7 to 10 days in patients with HAP/VAP without altering clinical cure rate or increasing infection relapse rate.

  • The panel suggests a 7- to 8-day antibiotic course for a patient with VAP without lung abscess, cavitation, immunodeficiency, cystic fibrosis, or necrotizing pneumonia and with a good clinical response. (Weak recommendation, moderate quality of evidence.)
  • Therapy should be individualized according to clinical response and appropriateness of initial empiric therapy provided; a routine antibiotic course for >3 days is not advised when the probability of HAP is low and there has been no deterioration within 72 hours of the onset of symptoms. (Weak recommendation, low quality of evidence.)

5. Bedside clinical assessment equivalency and/or serial biomarkers to detect adverse outcomes and clinical response to treatment for patients receiving antibiotics for VAP or HAP

  • The panel advises performing a bedside clinical evaluation of patient receiving antibiotic treatment for VAP or HAP.  (Good practice statement.)
  • The panel does not recommend routine assessment of biomarkers — including C-reactive protein (CRP), procalcitonin (PCT), copeptin, and mid-regional pro-atrial natriuretic peptide (MR-proANP) — at 72 to 96 hours to predict adverse events or clinical response. (Strong recommendation, moderate quality of evidence.)

6.    Use of serum PCT levels to reduce the duration of antibiotics in patients with HAP with severe sepsis or VAP

  • When the anticipated duration of antibiotic therapy is 7 to 8 days, the panel does not recommend routine serial measurement of serum PCT levels in patients with HAP or VAP to reduce the duration of treatment. (Strong recommendation, moderate quality of evidence.)
  • The panel advises combining clinical evaluation and serial PCT measurements to reduce antibiotic treatment duration in certain situations. (Good practice statement.)

7. Use of selective oral decontamination (SOD; topical application of antibiotics or chlorhexidine in the oropharynx) or selective digestive decontamination (SDD; topical application of antibiotics or chlorhexidine in the oropharynx and intestinal tract along with intravenous antibiotics) in patients requiring mechanical ventilation for >48 hours.

  • No recommendation was made regarding the use of chlorhexidine to perform SOD in patients requiring mechanical ventilation until more safety data are available.   (No formal recommendation.)
  • The panel suggests the use of SOD but not SDD when the risk of antibiotic-resistance is low and the consumption of antibiotics in the ICU is <1000 daily doses per 1000 days admitted. (Weak recommendation, low quality of evidence.)

While these new guidelines are intended primarily for respiratory medicine and critical care specialists who are treating adults, they may also be helpful for other physicians — such as internists, infectious disease specialists, pharmacists, and microbiologists — and policy makers. The panel proposed revising the guidelines again in 2020, unless new evidence warrants earlier revision.

Reference

Torres A, Niederman MS, Chastre J, et al.  International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). Eur Respir J. Sep 10;50(3). pii:1700582. doi:10.1183/13993003.00582-2017

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