Approach to managing VAP

To identify the pathogen, collect blood and, if possible, lower respiratory tract samples for Gram stain and culture, ideally before starting antibiotic therapy. Other investigations may also be required – see Microbiological investigations for VAP. For patients with immune compromise, consider performing investigations for a broader range of pathogens (see Aetiology of VAP in patients with immune compromise), and seek expert advice on whether to adjust empirical antibiotic therapy while awaiting the results.

For patients with sepsis or septic shock, start antibiotic therapy within 1 hour of development of sepsis or septic shock, immediately after blood samples are taken for culture. Collect lower respiratory tract samples as soon as possible; however, do not delay antibiotic administration to do so. For nonantibiotic management of sepsis or septic shock, see Resuscitation of patients with sepsis or septic shock.

The empirical therapy regimens for ventilator-associated pneumonia (VAP) are stratified according to the risk of Pseudomonas aeruginosa.

A minority of patients with VAP may be considered at low risk of infection with P. aeruginosa if all the following criteria are metMartin-Loeches, 2015Torres, 2017Zaragoza, 2020:

  • no intravenous antibiotics in preceding 90 days, excluding those for surgical antibiotic prophylaxis
  • no underlying lung disease
  • no immune compromise or solid cancer
  • no signs of septic shock
  • development of VAP within 5 days of admission to an intensive care unit
  • absence of gram-negative bacilli on Gram stain of respiratory tract samples, if availableYoshimura, 2022
  • local epidemiology does not indicate a high risk of P. aeruginosa in patients with VAP.

For empirical therapy for VAP in patients at low risk of infection with P. aeruginosa, see VAP in patients at low risk of infection with Pseudomonas aeruginosa.

For patients at increased risk of infection with P. aeruginosa, the empirical therapy regimens for VAP are active against a broad range of pathogens, including P. aeruginosa. Consider the need for additional therapy for VAP in patients at increased risk of P. aeruginosa who have:

If a patient develops VAP while being treated with broad-spectrum antibiotics (eg piperacillin+tazobactam), seek expert advice.