Update of the treatment of nosocomial pneumonia in the ICU

Abstract

In accordance with the recommendations of, amongst others, the Surviving Sepsis Campaign and the recently published European treatment guidelines for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), in the event of a patient with such infections, empirical antibiotic treatment must be appropriate and administered as early as possible. The aim of this manuscript is to update treatment protocols by reviewing recently published studies on the treatment of nosocomial pneumonia in the critically ill patients that require invasive respiratory support and patients with HAP from hospital wards that require invasive mechanical ventilation. An interdisciplinary group of experts, comprising specialists in anaesthesia and resuscitation and in intensive care medicine, updated the epidemiology and antimicrobial resistance and established clinical management priorities based on patients' risk factors. Implementation of rapid diagnostic microbiological techniques available and the new antibiotics recently added to the therapeutic arsenal has been reviewed and updated. After analysis of the categories outlined, some recommendations were suggested, and an algorithm to update empirical and targeted treatment in critically ill patients has also been designed. These aspects are key to improve VAP outcomes because of the severity of patients and possible acquisition of multidrug-resistant organisms (MDROs).

Keywords: Ceftazidime-avibactam; Ceftolozane-tazobactam; HAP; KPC; Nosocomial pneumonia; PCR; Pseudomonas aeruginosa; VAP.

Fig. 1

Physiopathological approach of progression of nosocomial pneumonia from wards to ICU. From green to red colour, the progression of the severity of nosocomial pneumonia is described independently of the area of hospital admission. vHAP shows the poorest outcome. HAP, hospital-acquired pneumonia; NV-ICUAP, non-ventilated acquired pneumonia; VAP, ventilator-acquired pneumonia; vHAP, ventilated hospital-acquired pneumonia

Fig. 2

PANNUCI algorithm. From empirical to targeted treatment on nosocomial pneumonia in ICU. After analyzing the onset, the previous use of antimicrobials or clinical condition (vHAP or VAP), empirical antimicrobial therapy is chosen based on risk factors, previous colonization, local flora and/or use of rapid techniques. Therefore, targeted therapy is selected depending on the type of microorganism isolated and the possible advantages of one antimicrobial over others. AT, antimicrobial therapy; vHAP, ventilated hospital-acquired pneumonia; VAP, ventilator-associated pneumonia; MDR, multidrug-resistant; PCR, polymerase chain reaction; CFT/TAZ, ceftolozane/tazobactam; CAZ/AVI, ceftazidime/avibactam; PIP/TAZ, piperacillin/tazobactam; AMG, aminoglycoside; AZT, aztreonam; EAT, empirical antimicrobial treatment; TAT, targeted antimicrobial treatment; OXA-48, OXA-48 carbapenemase; KPC, Klebsiella pneumoniae carbapenemase; R, resistance. *If Oxa-48 susceptible to CAZ/AVI