Review of patients with VAP

Review patients with ventilator-associated pneumonia (VAP) within 24 to 48 hours and reassess the diagnosis. If the response to initial empirical therapy is inadequate at 48 hours, reassess the diagnosis and seek expert advice. Consider infective and noninfective diagnoses (eg heart failure, aspiration pneumonitis) – see Approach to managing patients with VAP who are not improving. At 48 hours, if there is no strong evidence to support the diagnosis of VAP, stop antibiotic therapy.

Modify treatment based on the results of investigations, including susceptibility testing, if possible (see Directed therapy for pneumonia). Await the results of culture before narrowing therapy to treat staphylococcal or gram-negative pneumonia. See also De-escalation of therapy and intravenous to oral switch for VAP.

If vancomycin, gentamicin or tobramycin were added to the empirical therapy regimen, review the need for ongoing therapy at 24 to 48 hours. If the patient is improving and microbiological investigations exclude:

• methicillin-resistant Staphylococcus aureus (MRSA), consider stopping vancomycin
• resistant gram-negative bacteria and Pseudomonas aeruginosa, stop gentamicin or tobramycin.

Once treatment for pneumonia has started, the patient’s symptoms should steadily improve. The rate of recovery is influenced by the severity of pneumonia and the patient’s general health and comorbidities. Fever should subside within the first few days of appropriate antibiotic therapy and appetite should improve. Cough, sputum production (if present), chest discomfort and breathlessness may take several weeks to resolve and are often due to exacerbations of comorbidities (eg heart failure). Patients may report exertional fatigue for months after an episode of pneumonia due to deconditioning; however, its presence requires exclusion of other causes. Prolonged symptoms are not an indication for extended antibiotic therapy.