International Conference for the Development of Consensus on the Diagnosis and Treatment of Ventilator-Associated Pneumonia

doi:10.1378/chest.120.3.955

Chest

Volume 120, Issue 3, September 2001, Pages 955-970

https://doi.org/10.1378/chest.120.3.955 Get rights and content

Abstract

Ventilator-associated pneumonia (VAP) is an important health problem that still generates great controversy. A consensus conference attended by 12 researchers from Europe and Latin America was held to discuss strategies for the diagnosis and treatment of VAP. Commonly asked questions concerning VAP management were selected for discussion by the participating researchers. Possible answers to the questions were presented to the researchers, who then recorded their preferences anonymously. This was followed by open discussion when the results were known. In general, peers thought that early microbiological examinations are warranted and contribute to improving the use of antibiotherapy. Nevertheless, no consensus was reached regarding choices of antimicrobial agents or the optimal duration of therapy. Piperacillin/tazobactam was the preferred choice for empiric therapy, followed by a cephalosporin with antipseudomonal activity and a carbapenem. All the peers agreed that the pathogens causing VAP and multiresistance patterns in their ICUs were substantially different from those reported in studies in the United States. Pathogens and multiresistance patterns also varied from researcher to researcher inside the group. Consensus was reached on the importance of local epidemiology surveillance programs and on the need for customized empiric antimicrobial choices to respond to local patterns of pathogens and susceptibilities.

Section snippets

Materials and Methods

This conference was held on May 22, 2000, at the Hospital Joan XXIII, Tarragona, Spain. The consensus group consisted of 12 intensivists from Spain, Portugal, Argentina, and Uruguay. Jordi Rello, acting as conference coordinator and host, selected the peers, based on their interest and experience in the study and treatment of infectious diseases in the ICU, their previous participation in congresses, and their publications in the field.

The conference format followed roughly that of the

Terminology

A diagnosis of pneumonia was defined as the presence of new, persistent pulmonary infiltrates not otherwise explained, appearing on chest radiographs. Moreover, at least two of the following criteria also were required: (1) temperature of > 38°C; (2) leukocytosis > 10,000 cells/mm³; and (3) purulent respiratory secretions. A pneumonia was considered to be ventilator-associated when it occurred after intubation and was judged not to have incubated before an artificial airway was put in place.

Background Data:

Lower respiratory airways are uniformly colonized only a few hours after intubation²⁰²¹; therefore, the recovery of a pathogen is by no means sufficient for the diagnosis of infection. Not even the finding of a high concentration of colonies is diagnostic of pneumonia.²²²³ Blood cultures do not provide useful additional information.¹⁵²⁴ However, there is now clear evidence that episodes caused by methicillin-resistant S aureus (MRSA), P aeruginosa, or A baumannii present excess mortality

Summary

Although consensus was not reached on many of the questions, the conclusions of the conference can be summarized as follows.

The diagnosis of VAP on clinical grounds may provide adequate sensitivity when compared to other methods. Microbiological examinations are useful for the choice of the antibiotic regimen, and special emphasis was placed on the quality of the respiratory sample (ie, either invasive or noninvasive). Invasive diagnostic testing such as bronchoscopy may be required to improve

Acknowledgment

The conference participants gratefully acknowledge the support and helpful comments of Rafael Perez and Mercedes Rubio.

References (139)

R Celis et al.
Nosocomial pneumonia: a multivariate analysis of risk and prognosis
Chest
(1988)
RW Haley et al.
Nosocomial infections in US hospitals, 1975–76: estimated frequency by selected characteristics of patients
Am J Med
(1981)
PA Gross et al.
Deaths from nosocomial infections: experience in a university hospital and a community hospital
Am J Med
(1980)
J Fagon et al.
Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay
Am J Med
(1993)
RF Grossman et al.
Evidence-based assessment of diagnostic tests for ventilator-associated pneumonia
Chest
(2000)
CM Luna et al.
Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia
Chest
(1997)
J Rello et al.
The role of Candida spp isolated from bronchoscopic samples in nonneutropenic patients
Chest
(1998)
J Rello et al.
Impact of previous antimicrobial therapy on the etiology and outcome of ventilator-associated pneumonia
Chest
(1993)
J Chastre et al.
Diagnosis of nosocomial bacterial pneumonia in intubated patients undergoing ventilation: comparison of the usefulness of bronchoalveolar lavage and the protected specimen brush
Am J Med
(1988)
M Gallego et al.
Diagnostic testing for ventilator-associated pneumonia
Clin Chest Med
(1999)

RG Dotson et al.

The effect of antibiotic therapy on recovery of intracellular bacteria from bronchoalveolar lavage in suspected ventilator-associated pneumonia

Chest

(1993)

JF Timsit et al.

Usefulness of airway visualization in the diagnosis of nosocomial pneumonia in ventilated patients

Chest

(1996)

PJ Torzillo et al.

Use of protected telescoping brush system in the management of bacterial pulmonary infection in intubated patients

Br J Dis Chest

(1985)

RP Baughman et al.

Use of the protected specimen brush in patients with endotracheal or tracheostomy tubes

Chest

(1987)

RS Lambert et al.

Comparison of tracheal aspirates and protected brush catheter specimens for identifying pathogenic bacteria in mechanically ventilated patients

Am J Med Sci

(1989)

GD Campbell

Blinded invasive diagnostic procedures in ventilator-associated pneumonia

Chest

(2000)

CH Marquette et al.

Protected specimen brush in the assessment of ventilator-associated pneumonia: selection of a certain lung segment for bronchoscopic sampling is unnecessary

Chest

(1993)

D Cook et al.

Endotracheal aspiration in the diagnosis of ventilator-associated pneumonia

Chest

(2000)

EH Ibrahim et al.

A comparative analysis of patients with early-onset vs late-onset nosocomial pneumonia in the ICU setting

Chest

(2000)

J Rello et al.

Incidence, etiology and outcome of nosocomial pneumonia in mechanically ventilated patients

Chest

(1991)

T Horan et al.

Pathogens causing nosocomial infections

Antimicrobial Newsletter

(1988)

CM Luna et al.

Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia

Chest

(1997)

EH Ibrahim et al.

The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting

Chest

(2000)

MS Niederman et al.

Pneumonia in the critically ill hospitalized patient

Chest

(1990)

J Rello et al.

Pneumonia due to Haemophilus influenzae among mechanically ventilated patients: incidence, outcome and risk factors

Chest

(1992)

SC Brewer et al.

Ventilator-associated pneumonia due to Pseudomonas aeruginosa

Chest

(1996)

RJ Mangi et al.

Cefoperazone versus combination antibiotic therapy of hospital-acquired infection

Am J Med

(1988)

JJ Schentag et al.

Treatment with aztreonam or tobramycin in critical care patients with nosocomial Gram-negative rod pneumonia

Am J Med

(1985)

M Hilf et al.

Antibiotic therapy for Pseudomonas aeruginosa bacteremia: outcome correlations in a prospective study of 200 patients

Am J Med

(1989)

EL Chan et al.

Determination of synergy by two methods with eight antimicrobial combinations against tobramycin-susceptible and tobramycin-resistant strains of Pseudomonas aeruginosa

Diagn Microbiol Infect Dis

(1987)

AB Carter et al.

Therapy for ventilator-associated pneumonia

Clin Chest Med

(1999)

J Rello

Acinetobacter baumannii infection in the ICU: customization is the key

Chest

(1999)

M Kollef

Ventilator-associated pneumonia

JAMA

(1993)

A Torres et al.

Incidence, risk and prognosis factors of nosocomial pneumonia in mechanically ventilated patients

Am Rev Respir Dis

(1990)

DE Craven et al.

Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation

Am Rev Respir Dis

(1986)

DK Heyland et al.

The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient: the Canadian Critical Trials Group

Am J Respir Crit Care Med

(1999)

J Freeman et al.

Adverse effects of nosocomial infection

J Infect Dis

(1979)

J Boyce et al.

Nosocomial pneumonia in Medicare patients: hospital costs and reimbursement patterns under the prospective payment system

Arch Intern Med

(1991)

M Niederman et al.

Invasive diagnostic testing is not needed routinely to manage suspect ventilator-associated pneumonia

Am J Respir Crit Care Med

(1994)

J Chastre et al.

Invasive diagnostic testing should be routinely used to manage ventilated patients with suspected pneumonia

Am J Respir Crit Care Med

(1994)

American Thoracic Society

Hospital acquired pneumonia in ventilated patients: diagnosis, assessment of severity, initial antimicrobial therapy and preventative strategies

Am J Respir Crit Care Med

(1995)

J Rello et al.

The value of routine microbiological investigation in ventilator-associated pneumonia

Am J Respir Crit Care Med

(1997)

MH Kollef et al.

The influence of mini-BAL cultures on patient outcome: implications for the antibiotic management of ventilator-associated pneumonia

Chest

(1998)

Alvarez-Lerma

Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit: the ICU-acquired Pneumonia Study Group

Intensive Care Med

(1996)

JE Edwards et al.

International Conference for the Development of a Consensus on the Management and Prevention of Severe Candida Infections

Clin Infect Dis

(1997)

W Johanson et al.

Nosocomial respiratory infections with Gram-negative bacilli

Ann Intern Med

(1972)

H Correa et al.

Infeccion pulmonar en paciente con asistencia respiratoria

Arch Med Int

(1982)

CHS Garrard et al.

The diagnosis of pneumonia in the critically ill

Chest

(1995)

J Rello et al.

Lack of usefulness of blood cultures to diagnose ventilator-associated pneumonia

Eur Respir J

(1991)

J Rello et al.

Ventilator-associated pneumonia by Staphylococcus aureus: comparison of methicillin-resistant and methicillin-sensitive episodes

Am J Respir Crit Care Med

(1994)

Cited by (198)

Predictive Factors of Fever After Aneurysmal Subarachnoid Hemorrhage and Its Impact on Delayed Cerebral Ischemia and Clinical Outcomes
2018, World Neurosurgery
Fever is relatively common and worsens neurologic injury after aneurysmal subarachnoid hemorrhage (SAH). The aim of this study was to display the time course of body temperature, identify predictive factors of fever after SAH, and evaluate its impact on delayed cerebral ischemia (DCI) and clinical outcomes.
Four hundred twelve patients with SAH and ruptured aneurysms who were treated at our institution between January 2007 and December 2016 were analyzed retrospectively. The febrile group was defined as patients having a maximal temperature ≥38.0°C for 2 consecutive days or for more than 3 days within 2 weeks after SAH, and the remaining patients comprised the afebrile group. The impact of fever on DCI and clinical outcomes was assessed.
Anterior communicating artery aneurysm, Hunt and Hess grade, SAH sum score, intraventricular hemorrhage sum score, and body mass index were independent predictive factors for fever after SAH. A larger SAH and fever were independent risk factors for DCI. A worse Hunt and Hess grade, concomitant intracerebral hemorrhage, DCI, old age, and fever were independent risk factors for unfavorable outcomes.
Predictors of fever after SAH were a worse clinical status at admission, larger SAH and intraventricular hemorrhage, anterior communicating artery aneurysm, and greater body mass index. Fever itself was an independent risk factor for DCI and unfavorable outcomes after aneurysmal SAH.
Haplotypes composed of minor frequency single nucleotide polymorphisms of the TNF gene protect from progression into sepsis: A study using the new sepsis classification
2018, International Journal of Infectious Diseases
Several articles have provided conflicting results regarding the role of single nucleotide polymorphisms (SNPs) in the promoter region of the TNF gene in susceptibility to sepsis. Former articles have been based on previous definitions of sepsis. This study investigated the influence of TNF haplotypes on the development of sepsis using the new Sepsis-3 definitions.
DNA was isolated from patients suffering from infection and systemic inflammatory response syndrome. Haplotyping was performed for six SNPs of TNF. The serum levels of tumour necrosis factor alpha (TNF-α) of these patients were measured using an enzyme immunosorbent assay. Patients were classified into infection and sepsis categories using the Sepsis-3 definitions. Associations between the TNF haplotypes and the clinical characteristics and serum TNF-α levels of the patients were examined.
The most common TNF haplotype h1 was composed of major alleles of the studied SNPs. Carriage of haplotypes composed of minor frequency alleles was associated with a lower risk of developing sepsis (odds ratio 0.41, 95% confidence interval 0.19–0.88, p = 0.022), but this did not affect the 28-day outcome. Serum TNF-α levels were significantly higher among patients homozygous for h1 haplotypes who developed sepsis compared to infection (p = 0.032); a similar result was not observed for patients carrying other haplotypes.
Haplotypes containing minor frequency SNP alleles of TNF protect against the development of sepsis without affecting the outcome.
JAID/JSC Guidelines for the Treatment of Respiratory Infectious Diseases: The Japanese Association for Infectious Diseases/Japanese Society of Chemotherapy – The JAID/JSC Guide to Clinical Management of Infectious Disease/Guideline-preparing Committee Respiratory Infectious Disease WG
2016, Journal of Infection and Chemotherapy
The impact of onset time on the isolated pathogens and outcomes in ventilator associated pneumonia
2016, Journal of Infection and Public Health
Several guidelines base the empirical therapy of ventilator-associated pneumonia (VAP) on the time of onset. However, there is emerging evidence that the isolated microorganisms may be similar regardless of onset time. This study evaluated the characteristics and outcomes of VAP with different onset times. All of the mechanically ventilated patients admitted to the ICU of a 900-bed tertiary-care hospital between 01/08/2003 and 31/12/2010 were prospectively followed for VAP development according to the National Healthcare Safety Network criteria. The patients were categorized into four groups: EO if VAP occurred within 4 days of intubation and hospital admission; LO if VAP occurred after 4 days of admission; EL if VAP occurred within 4 days of intubation, but after the fourth hospitalization day; and LL if VAP occurred after the fourth day of intubation and hospitalization. Out of the 394 VAP episodes, 63 (16%) were EO episodes, 331 (84.0%) were LO episodes, 40 (10.1%) were EL episodes and 291 (73.1%) were LL episodes. The isolated microorganisms were comparable among the four groups, with a similar rate of potentially multidrug resistant organisms in the EO-VAP (31.7%), LO-VAP (40.8%), EL-VAP (37.5%) and LL-VAP (43.3%) samples. The hospital mortality was 24% for EO-VAP cases, 28% for LO-VAP cases, 40% for EL-VAP cases and 49% for LL-VAP cases. However, in the adjusted multivariate analysis, neither LO-VAP, EL-VAP nor LL-VAP was associated with an increased risk of hospital mortality compared with EO-VAP (OR, 0.86 95% CI, 0.34–2.19; 1.22; 95% CI, 0.41–3.68, and 0.95; 95% CI, 0.43–2.10, respectively). In this study, the occurrence of potential multidrug resistant pathogens and the mortality risk were similar regardless of VAP timing from hospital admission and intubation. The bacterial isolates obtained from the VAP cases did not follow an early vs. late-onset pattern, and thus, these terms may not be clinically helpful.
Polymicrobial bloodstream infections: Epidemiology and impact on mortality
2013, Journal of Global Antimicrobial Resistance
The aim of this study was to investigate the impact of polymicrobial bloodstream infections (pBSIs) on the outcome of sepsis in an area where antimicrobial resistance is of concern. This was a retrospective analysis of data collected prospectively from patients developing BSI outside of an intensive care unit (non-ICU patients) or after ICU admission. Demographics and clinical characteristics were compared for patients with pBSI versus monomicrobial BSI (mBSI) and following stratification by ICU or non-ICU and severity of sepsis status. Possible risk factors for adverse outcome were explored by multivariate analysis, and outcomes were measured by Cox regression analysis. Among 412 patients with BSI, 47 patients (11.4%) with pBSI were recorded; compared with patients with mBSI, they had significantly higher APACHE II scores and presented more frequently with severe sepsis/septic shock. The all-cause 28-day mortality was significantly higher for pBSI versus mBSI (38.3% vs. 24.7%; P = 0.033), whereas appropriateness of treatment was comparable (78.7% vs. 86.6%). Primary bacteraemia by combinations of Enterococcus faecalis, Klebsiella pneumoniae and Acinetobacter baumannii was predominant among pBSIs; in mBSIs, urinary tract infections by Escherichia coli, K. pneumoniae or Pseudomonas aeruginosa predominated. Multivariate analysis demonstrated pBSI as a significant contributor to 28-day mortality (HR = 1.86; P = 0.039), along with presence of two or more co-morbidities (HR = 2.35; P = 0.004). In conclusion, pBSIs differed epidemiologically from mBSIs, with the emergence of enterococcal species, and portended an almost two-fold increased risk of 28-day mortality. Prospective studies are warranted to elucidate possibly modifiable factors.
Genetic polymorphisms within tumor necrosis factor gene promoter region: A role for susceptibility to ventilator-associated pneumonia
2012, Cytokine
Debatable findings exist among various studies regarding the impact of single nucleotide polymorphisms (SNPs) within the promoter region of the tumor necrosis factor (TNF) gene for susceptibility to infections. Their impact was investigated in a cohort of mechanically ventilated patients who developed ventilator-associated pneumonia (VAP). Two-hundred and thirteen mechanically ventilated patients who developed VAP were enrolled. Genomic DNA was extracted and SNPs at the −376, −308 and −238 position of the promoter region of the TNF gene were assessed by restriction fragment length polymorphisms. Monocytes were isolated from 47 patients when they developed sepsis and stimulated by bacterial endotoxin for the production of TNFα and of interleukin-6 (IL-6). Patients were divided into two groups; 166 patients bearing only wild-type alleles of all three studied polymorphisms; and 47 patients carrying at least one A allele of the three studied SNPs. Time between start of mechanical ventilation and advent of VAP was significantly shorter in the second group than in the first group (log-rank: 4.416, p: 0.041). When VAP supervened, disease severity did not differ between groups. Stimulation of TNFα and of IL-6 was much greater by monocytes for patients carrying A alleles. Carriage of at least one A allele of the three studied SNPs at the promoter region of the TNF-gene is associated with shorter time to development of VAP but it is not associated with disease severity. Findings may be related with a role of the studied SNPs in the production of pro-inflammatory cytokines.

View all citing articles on Scopus

: This conference was supported by an educational grant from the Fundació d’Investigació Sant Pau (Barcelona, Spain), and CIRIT© (grant No. 2000-SGR-128).

View full text

Chest

Consensus ConferenceInternational Conference for the Development of Consensus on the Diagnosis and Treatment of Ventilator-Associated Pneumonia

Abstract

Section snippets

Materials and Methods

Terminology

Background Data:

Summary

Acknowledgment

Chest

Am J Med

Am J Med

Am J Med

Chest

Chest

Chest

Chest

Am J Med

Clin Chest Med

Chest

Chest

Br J Dis Chest

Chest

Am J Med Sci

Chest

Chest

Chest

Chest

Chest

Antimicrobial Newsletter

Chest

Chest

Chest

Chest

Chest

Am J Med

Am J Med

Am J Med

Diagn Microbiol Infect Dis

Clin Chest Med

Chest

Ventilator-associated pneumonia

JAMA

Incidence, risk and prognosis factors of nosocomial pneumonia in mechanically ventilated patients

Am Rev Respir Dis

Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation

Am Rev Respir Dis

The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient: the Canadian Critical Trials Group

Am J Respir Crit Care Med

Adverse effects of nosocomial infection

J Infect Dis

Nosocomial pneumonia in Medicare patients: hospital costs and reimbursement patterns under the prospective payment system

Arch Intern Med

Invasive diagnostic testing is not needed routinely to manage suspect ventilator-associated pneumonia

Am J Respir Crit Care Med

Invasive diagnostic testing should be routinely used to manage ventilated patients with suspected pneumonia

Am J Respir Crit Care Med

Hospital acquired pneumonia in ventilated patients: diagnosis, assessment of severity, initial antimicrobial therapy and preventative strategies

Am J Respir Crit Care Med

The value of routine microbiological investigation in ventilator-associated pneumonia

Am J Respir Crit Care Med

The influence of mini-BAL cultures on patient outcome: implications for the antibiotic management of ventilator-associated pneumonia

Chest

Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit: the ICU-acquired Pneumonia Study Group

Intensive Care Med

International Conference for the Development of a Consensus on the Management and Prevention of Severe Candida Infections

Clin Infect Dis

Nosocomial respiratory infections with Gram-negative bacilli

Ann Intern Med

Infeccion pulmonar en paciente con asistencia respiratoria

Arch Med Int

The diagnosis of pneumonia in the critically ill

Chest

Lack of usefulness of blood cultures to diagnose ventilator-associated pneumonia

Eur Respir J

Ventilator-associated pneumonia by Staphylococcus aureus: comparison of methicillin-resistant and methicillin-sensitive episodes

Am J Respir Crit Care Med

Consensus Conference
International Conference for the Development of Consensus on the Diagnosis and Treatment of Ventilator-Associated Pneumonia