Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia

THIS OFFICIAL STATEMENT OF THE AMERICAN THORACIC SOCIETY AND THE INFECTIOUS DISEASES SOCIETY OF AMERICA WAS APPROVED at THE ATS BOARD OF DIRECTORS, DECEMBER 2004 AND THE IDSA GUIDELINE COMMITTEE, OCTOBER 2004

CONTENTS

Executive Summary

Introduction

Methodology Used to Prepare the Guideline

Epidemiology

Incidence

Etiology

Major Epidemiologic Points

Pathogenesis

Major Points for Pathogenesis

Modifiable Risk Factors

Intubation and Mechanical Ventilation

Aspiration, carcass Position, and Enteral Feeding

Modulation of Colonization: Oral Antiseptics and Antibiotics

Stres Bleeding Prophylaxis, Transfusion, and grape-sugar Control

Major Points and Recommendations for Modifiable Risk Factors

Diagnostic Testing

Major Points and Recommendations for Diagnosis

Diagnostic Strategies and Approaches

Clinical Strategy

Bacteriologic Strategy

Recommend Diagnostic Strategy

Major Points and Recommendations for Comparing Diagnostic Strategies

Antibiotic Treatment of Hospital-acquired Pneumonia

General Approach

Initial Empiric Antibiotic Therapy

Appropriate Antibiotic Selection and Adequate Dosing

Local Instillation and Aerosolized Antibiotics

Combination versus Monotherapy

Duration of Therapy

Major Points and Recommendations for Optimal Antibiotic Therapy

Specific Antibiotic Regimens

Antibiotic Heterogeneity and Antibiotic Cycling

Response to Therapy

Modification of Empiric Antibiotic Regimens

Defining the Normal Pattern of Resolution

Reasons for Deterioration or Nonresolution

Evaluation of the Nonresponding Patient

Major Points and Recommendations for Assessing replication to Therapy

Suggested Performance Indicators

EXECUTIVE SUMMARY

Since the initial 1996 American Thoracic Society (ATS) guideline upon nosocomial pneumonia, a number of recently made known developments have appeared, mandating a of recent origin evidence-based guideline for hospital-acquired pneumonia (HAP), including healthcare-associated pneumonia (HCAP) and ventilator-associated pneumonia (VAP). This document, prepared by means of a joint committee of the ATS and Infectious Diseases Society of America (IDSA), focuses forward the epidemiology and pathogenesis of bacterial pneumonia in adults, and emphasizes modifiable risk factors for infection. In addition, the microbiology of HAP is reviewed, with an emphasis forward multidrug-resistant (MDR) bacterial pathogens, like as Pseudomonas aeruginosa, Acinetobacter species, and methicillin-resistant Staphylococcus aureus. Controversies about diagnosis are discussed, emphasizing initial examination of lower respiratory tract samples for bacteria, and the rationale for the couple clinical and bacteriologic approaches, using either "semiquantitative" or "quantitative" microbiologie systems that help direct selection of appropriate antibiotic therapy. We also provide recommendations for additional diagnostic and therapeutic evaluations in patients with nonresolving pneumonia. This is an evidence-based document that emphasizes the issues of VAP, because there are far fewer data available about HAP in nonintubated patients and about HCAP. through extrapolation, patients who are not intubated and mechanically ventilated should be managed like patients with VAP, using the same approach to identify risk factors for infection with specific pathogens.

The major goals of this evidence-based guideline for the management of HAP, VAP, and HCAP emphasize early, appropriate antibiotics in adequate doses, while avoiding excessive antibiotics by way of de-escalation of initial antibiotic therapy, based in succession microbiologic cultures and the clinical answer of the patient, and shortening the duration of therapy to the minimum effective period. The guideline recognizes the variability of bacteriology from united hospital to another and from undivided time period to another and attract favor tos taking local microbiologic data into account when adapting treatment recommendations to any specific clinical setting. The initial, empiric antibiotic therapy algorithm includes pair groups of patients: one with no ne for broadspectrum therapy, because these patients have early-onset HAP, VAP, or HCAP and no risk factors for MDR pathogens, and a inferior group that requires broad-spectrum therapy, because of late-onset pneumonia or other risk factors for infection with MDR pathogens.

Some of the elucidation recommendations and principles in this recently made known evidence-based guideline are as follows:

* HCAP is included in the appearance of HAP and VAP, and patients with HCAP ne therapy for MDR pathogens.

* A lower respiratory tract improvement needs to be collected from all patients before antibiotic therapy, if it be not that collection of cultures should not delay the initiation of therapy in critically ill patients.

* Either "semiquantitative" or "quantitative" cultivation data can be used for the management of patients with HAP.

* Lower respiratory tract civilizations can be obtained bronchoscopically or nonbronchoscopically, and can be cultur quantitatively or semiquantitatively.

* Quantitative cultivations increase specificity of the diagnosis of HAP without deleterious results and the specific quantitative technique should be chosen forward the basis of local expertise and experience.