[size=20px]A 15-year old patient with polytrauma has been intubated in the intensive care unit for one week. He develops a fever and thick yellow sputum. His white blood cell count is 19,000. A chest radiograph shows left lower lobe infiltrate. Initial treatment for this presumed ventilator associated pneumonia should include

 

A antifungal therapy.

 

B antiviral therapy.

 

C anti-Pseudomonas therapy.

 

D proton pump inhibitor.

 

E awaiting results of lower respiratory tract sputum sample.[/size]

C

C

correct

 

The predominant pathogens associated with ventilator associated pneumonias (VAP) are gram negative bacteria. Current Infectious Diseases Society of America guidelines call for a lower respiratory tract sample for culture if VAP is suspected. Empiric antibiotic therapy is started immediately. In a patient with low risk for multiple drug resistance (MDR) the recommended initial antibiotics include ceftriaxone, fluroquinolones, ampicillin sulbactam or ertapenem. If a patient has been intubated for greater than five days or has high risk factors for multidrug resistant pathogens, then the antibiotics started should cover MDR organisms. Pseudomonas and methicillin resistant Staphylcoccal aureus should be covered. Antibiotics are given for 48 to 72 hours and changed in accordance with culture results.

 

There is no single measure that has been shown to decrease the incidence of VAP in adult or pediatric patients. Most studies have proposed a bundle whereby several measures are applied to decrease the incidence of VAP.

• at least once daily assessment for readiness to extubate (SHEA Quality of Evidence Grade II pediatric, Grade III neonates)
  
• elevation of the head of bed 30 to 45 degrees (Grade III pediatric and neonates)
  
• minimizing disruption of circuit (Grade II pediatric, Grade III neonates)
  
• oral hygiene every 12 hours (Grade II pediatrics, no evidence in neonates)
  

The circuit should be examined for condensation or contamination at least every eight hours with subsequent drainage of condensation and changing of visibly soiled circuit.

 

Routine changing of the circuit when there is no contamination is discouraged.