CHEST Guidelines-Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia

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The 2016 Clinical Practice Guidelines for managing adults with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) emphasize evidence-based strategies for diagnosis and treatment. These guidelines differentiate between HAP, occurring without mechanical ventilation, and VAP. Key recommendations include:

1. <strong>Diagnosis Methods</strong>: For VAP diagnosis, noninvasive sampling with semiquantitative cultures is suggested, as it is more rapid and resource-efficient. When invasive sampling is conducted, if culture results fall below diagnostic thresholds, withholding antibiotics is suggested to prevent unnecessary antibiotic exposure and resistance.

2. <strong>Antibiotic Guidelines</strong>: Empiric treatment of VAP should cover S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli. Adding MRSA coverage is recommended for patients at risk of antimicrobial resistance. In HAP, coverage should consider S. aureus and gram-negative bacilli, tailoring therapy based on local antibiograms and patient risk. De-escalation of antibiotics is generally recommended.

3. <strong>Biomarkers in Treatment Decisions</strong>: The initiation of antibiotics should rely on clinical criteria rather than biomarkers like procalcitonin (PCT) due to insufficient accuracy in identifying HAP/VAP.

4. <strong>Duration of Therapy</strong>: For VAP, a 7-day antibiotic course is recommended, with consideration for patient-specific factors that might necessitate adjustments. In HAP, the same 7-day course is advised despite very low-quality evidence.

5. <strong>Inhaled Antibiotics</strong>: In cases of VAP caused by gram-negative bacilli sensitive only to aminoglycosides or polymyxins, the addition of inhaled antibiotics to systemic therapy is suggested, particularly when options are limited.

6. <strong>Pathogen-Specific Approaches</strong>: Vancomycin or linezolid is recommended for MRSA HAP/VAP. For P. aeruginosa infections, treatment should be guided by antimicrobial susceptibility testing, avoiding aminoglycoside monotherapy.

The guidelines underscore the importance of individualizing treatment based on patient risk factors, local pathogen profiles, and susceptibility patterns to ensure effective management and reduce the impact of antibiotic resistance.

Keywords

hospital-acquired pneumonia

ventilator-associated pneumonia

diagnosis methods

antibiotic guidelines

biomarkers

duration of therapy

inhaled antibiotics

pathogen-specific approaches

antimicrobial resistance

evidence-based strategies