Ventilator-associated pneumonia (VAP) Ventilator-associated pneumonia (VAP) is defined as nosocomial pneumonia in a patient on mechanical ventilatory support (by endotracheal tube or tracheostomy) for >48 hours.

Ventilator-associated pneumonia (VAP) continues to complicate the course of 8 to 28% of patients receiving mechanical ventilation (MV) (other dates – 10 – 25 – – 54 % ). The mortality rate for VAP ranges from 24 to 50% and can reach 76% in some specific settings or when lung infection is caused by high-risk pathogens(crude mortality rates of 10% to 40%, attributable mortality rates of 5% to 27%).

Ethiology Staphylococcus aureus ( 12,9 %) Pseudomonas aeruginosa ( 17 %) Enterobacteriaceae ( 9,4 %) Klebsiella spp. – ( 11,6 %) Other (E. coli, Proteus spp., Acinetobacter spp., Serratia marcescens; Candida)

Pathogenesis The pathogenesis of ventilator-associated pneumonia probably involves microaspiration of oropharyngeal or gastric secretions contaminated with these organisms. The contamination source may be: Other people (cross-infection) Contaminated objects (environmental infection) Self patient (autoinfection) aspiration haematogen

Low organism resistance (age, immunosuppression) Colonization of oropharynx, gaster Gastric reflux, aspiration Necessity of longtime ventilation with possible contamination of the equipment Difficult trachea readjustment Most important factors

Early-onset ventilator-associated pneumonia (<4 days of mechanical ventilation), caused by typically antibiotic-susceptible community-acquired bacteria. Late-onset ventilator-associated pneumonia ( 4 days of mechanical ventilation) caused by commonly antibiotic-resistant nosocomial organisms. Groups

Prevention Semi-Recumbent Positioning (45 *) Stress Ulcer Prophylaxis (+-) Aspiration of Subglottic Secretions (+-) Continuous Oscillation may be effective in surgical patients or patients with neurologic problems (grade I). Selective Digestive Tract Decontamination (not long time) Ventilator Circuit Management Strategies (aseptic, mucolitic) Methods of Enteral Feeding (no difference (?))

Criteria for diagnosis There are no standardized criteria for the diagnosis of ventilator- associated pneumonia, but typically three or more of the following are required: Fever Leukocytosis Purulent secretions An infiltrate on chest radiography Stricter definitions require a microbiological diagnosis as well, either by endotracheal aspirate, protected-specimen brush, or quantitative bronchoalveolar lavage

Treatment Appropriate initial empirical therapy aminoglycoside or a fluoroquinolone and a broad-spectrum betalactam antimicrobial agent Treatment based on definitive microbiologic results identifying the pathogen(s) and its susceptibility patterns

S.pneumoniae, H.influenzae, S.aureus Rannaia P.aeruginosa, Acinetobacter spp., представителями семейства Enterobacteriaceae и реже MRSA.