Targeted antibiotic management of ventilator-associated pneumonia

Immediate administration of adequate antibiotic therapy is critical to improving survival in patients with ventilator-associated pneumonia (VAP). At the same time, appropriate antimicrobial stewardship includes not only limiting the use of inappropriate agents in patients with VAP, but also, improving our ability to diagnose and exclude infection in the intensive care unit (ICU). Particular obstacles include: the differentiation between colonisation and infection of the lower respiratory tract; the interpretation of non-specific clinical signs and symptoms suggestive of lung infection; and the optimal use of antibiotics in the ICU. 'Clinical' management of VAP involves the initiation of empirical therapy based on risk-factors, qualitative microbiological tests and local bacterial resistance patterns, and its subsequent adjustment according to culture results. 'Bacteriological' management with direct examination and quantitative culturing of specimens obtained using fibreoptic bronchoscopy, e.g., bronchoalveolar lavage and/or by protected specimen brush techniques, helps to better direct initial antibiotic therapy, as well as to confirm the diagnosis of VAP.