ESICM/ESCMID/ALAT guidelines for the management of HAP and VAP

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) Recently published guidelines for management of hospital acquired pneumonia(HAP), and ventilator associated pneumonia.

These guidelines are sligtly different then presented by IDSA and ATS published in July 2016. Some of the differences in the initial treatment and the definitions.

DEFINITIONS

Hospital-acquired pneumonia (HAP) is an infection of the pulmonary parenchyma caused by pathogens that are present in hospital settings.

Nosocomial pneumonia develops in patients admitted to the hospital for >48 h and usually the incubation period is at least 2 days.

Ventilator-associated pneumonia (VAP) develops in intensive care unit (ICU) patients who have been mechanically ventilated for at least 48 h.

Ventilator-associated tracheobronchitis (VAT) is characterised by signs of respiratory infection without new radiographic infiltrates, in a patient who has been ventilated for at least 48 h.

 

MAIN RECOMMENDATIONS

The guidelines that in question-and-answer format, which men the answers seven important questions.

Here is a summary in the table form

 

1.      Should distal qualitative samples be obtained in patients ventilator  associated pneumonia? Yes, prior to starting antimicrobial therapy
2.     Can patients who are suspected to have a early-onset nosocomial infection, with low risk MDR be treated with narrow spectrum antibiotics? Yes, ertapenem, ceftriaxone, cefotaxime, moxifloxacin or levofloxacin are recommended agents
3.     When using initial broad-spectrum empiric therapy, for HAP/VAP, should it always be with two drugs or can it be with one drug ? For high-risk HAP/VAP patients who present HAP/VAP and either septic shock and/or the following risk factors ( previous antibiotic use, recent prolonged hospital stay (>5 days of hospitalisation) and previous colonisation with MDR pathogens.

For low-risk patients, single drug can be used.

4.     In patients with HAP/VAP, can duration of antimicrobial therapy be shortened to 7–10 days ? 7–8-day course of antibiotic therapy in patients with

VAP without immunodeficiency, cystic fibrosis, empyema, lung

abscess, cavitation or necrotising pneumonia and with a good clinical response to therapy

5.     In patients receiving antibiotic treatment for VAP or

HAP, is bedside clinical assessment equivalent to the detection

of serial biomarkers to predict adverse outcomes/clinical response at 72–96 h?

Routine bedside assessment should be done, but not the biomarkers.
6.     Can serum PCT be used to reduce the duration of antibiotic therapy No
7.     In patients requiring mechanical ventilation for >48 h, does topical application of nonabsorbable antimicrobials (antibiotics or chlorhexidine) in the oropharynx (SOD) or in the oropharynx and intestinal tract along with intravenous antibiotics (SDD) reduce the risk of VAP occurrence and/or improve patient outcome compared with standard care? No recommendation for chlorhexidine, but suggest to use it.

Against systemic antibiotics (SDD)

 

DIFFERENCES FROM ATS/ IDSA GUIDELINES

  1. There are different definitions for VAP and HAP.
  2. Use of ventilator bundles is more popular in the United States.
  3. Due to presence of prior authorization for use of broad-spectrum antibiotics, Broad-spectrum antibiotics infrequently used in Europe.  IDSA/APS guidelines recommend targeting at least 95% of the potential organisms.
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