Infectious Diseases I

Preferentially use multimodal strategies and medications other than benzodiazepines to

manage agitation.

ii.

Use a protocol to minimize sedation.

iii.

Implement a ventilator liberation protocol.

Maintain and improve physical conditioning, provide early exercise and mobilization.

Maintain integrity of mechanical ventilator circuit.

Provide oral care with toothbrushing but without chlorhexidine.

Avoid oral care with chlorhexidine to prevent VAP in patients per recent joint recommendations by

SHEA/IDSA/APIC. Meta-analyses have shown no benefit and the potential of higher mortality rates

for patients receiving chlorhexidine oral care.

May consider use of selective oropharynx and digestive decontamination in ICUs with low

prevalence of antibiotic resistance organisms.

Avoid the use of probiotics to prevent VAP in mechanically ventilated patients. While some meta-

analyses found there might be a benefit, a recent large randomized controlled trial found no difference

The diagnostic approach for VAP includes (1) determining whether clinical signs and symptoms are

caused by pneumonia and (2) if pneumonia is present, identifying the causative pathogen(s), preferably

using lower respiratory tract culture.

bacteriologically confirmed pneumonia.

Clinical signs and symptoms of pneumonia include new or changing infiltrate on chest radiograph and

at least two of the following:

Elevated WBC

Fever (e.g., temperature greater than 100.4°F [38°C])

Macroscopically purulent sputum production

Lower respiratory tract cultures can be obtained through noninvasive or invasive techniques and

reported as qualitative, semiquantitative, or quantitative.

Quantitative (expressed as CFU/mL) and semiquantitative (expressed as rare/few to many) cultures

using recommended diagnostic growth thresholds are more specific than qualitative cultures for

identifying the causative pathogen.

Noninvasive techniques: Tracheal aspirate from endotracheal or tracheostomy tube – proximal to

distal sampling (depending on depth of sample) of upper airway secretions; usually semiquantitative

Invasive techniques

Blind, catheter-directed, or bronchoscopic BAL – Distal sampling of lung lobe/segment using

saline lavage; significant quantitative growth threshold above 10,000 or 100,000 CFU/mL

ii.

Bronchoscopic protected specimen brush (PSB) – Distal sampling of specific bronchial

segment; significant quantitative growth threshold above 1000 CFU/mL

speedily. Please see the Infectious Diseases II chapter for further discussion on the use of rapid

diagnostic tests in the ICU.

According to the current IDSA guidelines, the suggested diagnostic strategy for VAP includes clinical

suspicion and use of noninvasive sampling with semiquantitative cultures to diagnose VAP, rather than

invasive sampling or noninvasive sampling with quantitative cultures.