Borgatta Bárbara, Rello Jordi
Critical Care Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain.
BMC Infect Dis. 2014 Apr 30;14:211. doi: 10.1186/1471-2334-14-211.
Ventilator-associated pneumonia (VAP) is one of the most frequent clinical problems in ICU with an elevated morbidity and costs associated with it, in addition to prolonged MV, ICU-length of stay (LOS) and hospital-length of stay. Current challenges in VAP management include the absence of a diagnostic gold standard; the lack of evidence regarding contamination vs. airway colonization vs. infection; and the increasing antibiotic resistance. We performed a Pubmed search of articles addressing the management of ventilator-associated pneumonia (VAP). Immunocompromised patients, children and VAP due to multi-drug resistant pathogens were excluded from the analysis. When facing a patient with VAP, it's important to address a few key questions for the patient's optimal management: when should antibiotics be started?; what microorganisms should be covered?; is there risk for multirresistant microorganisms?; how to choose the initial agent?; how microbiological tests determine antibiotic changes?; and lastly, which dose and for how long?. It's important not to delay adequate treatment, since outcomes improve when empirical treatment is early and effective. We recommend short course of broad-spectrum antibiotics, followed by de-escalation when susceptibilities are available. Individualization of treatment is the key to optimal management.
呼吸机相关性肺炎（VAP）是重症监护病房（ICU）中最常见的临床问题之一，除了延长机械通气时间、ICU住院时间（LOS）和医院住院时间外，其发病率和相关费用也很高。目前VAP管理面临的挑战包括缺乏诊断金标准；缺乏关于污染与气道定植与感染的证据；以及抗生素耐药性不断增加。我们对发表在PubMed上的关于呼吸机相关性肺炎（VAP）管理的文章进行了检索。免疫功能低下的患者、儿童以及由多重耐药病原体引起的VAP被排除在分析之外。面对VAP患者时，为实现最佳管理，有几个关键问题需要解决：何时开始使用抗生素？；应覆盖哪些微生物？；是否存在多重耐药微生物的风险？；如何选择初始用药？；微生物检测如何决定抗生素的更换？；最后，使用何种剂量以及持续多长时间？。重要的是不要延迟适当的治疗，因为经验性治疗早期且有效时，治疗结果会得到改善。我们建议使用短疗程的广谱抗生素，在获得药敏结果后再进行降阶梯治疗。个体化治疗是实现最佳管理的关键。
