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Am. J. Respir. Crit. Care Med., Volume 165, Number 7, April 2002, 867-903

Ventilator-associated Pneumonia

Jean Chastre and Jean-Yves Fagon

Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière; and Service de Réanimation Médicale, Hôpital Européen Georges-Pompidou, Paris, France

Ventilator-associated pneumonia (VAP) continues to complicate the course of 8 to 28% of patients receiving mechanical ventilation (MV). In contrast to infections of more frequently involved organs (e.g., urinary tract and skin), for which mortality is low, ranging from 1 to 4%, the mortality rate for VAP ranges from 24 to 50% and can reach 76% in some specific settings or when lung infection is caused by high-risk pathogens. The predominant organisms responsible for infection are Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacteriaceae, but etiologic agents widely differ according to the population of patients in an intensive care unit, duration of hospital stay, and prior antimicrobial therapy. Because appropriate antimicrobial treatment of patients with VAP significantly improves outcome, more rapid identification of infected patients and accurate selection of antimicrobial agents represent important clinical goals. Our personal bias is that using bronchoscopic techniques to obtain protected brush and bronchoalveolar lavage specimens from the affected area in the lung permits physicians to devise a therapeutic strategy that is superior to one based only on clinical evaluation. When fiberoptic bronchoscopy is not available to physicians treating patients clinically suspected of having VAP, we recommend using either a simplified nonbronchoscopic diagnostic procedure or following a strategy in which decisions regarding antibiotic therapy are based on a clinical score constructed from seven variables. Selection of the initial antimicrobial therapy should be based on predominant flora responsible for VAP at each institution, clinical setting, information provided by direct examination of pulmonary secretions, and intrinsic antibacterial activities of antimicrobial agents and their pharmacokinetic characteristics. Further trials will be needed to clarify the optimal duration of treatment and the circumstances in which monotherapy can be safely used.




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T. A. Russo, Z. Wang, B. A. Davidson, S. A. Genagon, J. M. Beanan, R. Olson, B. A. Holm, P. R. Knight 3rd, P. R. Chess, and R. H. Notter
Surfactant dysfunction and lung injury due to the E. coli virulence factor hemolysin in a rat pneumonia model
Am J Physiol Lung Cell Mol Physiol, March 1, 2007; 292(3): L632 - L643.
[Abstract] [Full Text] [PDF]

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 J. Clin. Microbiol.Home page
N. D. Stone, C. M. O'Hara, P. P. Williams, J. E. McGowan Jr., and F. C. Tenover
Comparison of Disk Diffusion, VITEK 2, and Broth Microdilution Antimicrobial Susceptibility Test Results for Unusual Species of Enterobacteriaceae
J. Clin. Microbiol., February 1, 2007; 45(2): 340 - 346.
[Abstract] [Full Text] [PDF]

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 J Antimicrob ChemotherHome page
O. Burkhardt, V. Kumar, D. Katterwe, J. Majcher-Peszynska, B. Drewelow, H. Derendorf, and T. Welte
Ertapenem in critically ill patients with early-onset ventilator-associated pneumonia: pharmacokinetics with special consideration of free-drug concentration
J. Antimicrob. Chemother., February 1, 2007; 59(2): 277 - 284.
[Abstract] [Full Text] [PDF]

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 Am J Crit CareHome page
C. L. Cason, T. Tyner, S. Saunders, and L. Broome
Nurses' Implementation of Guidelines for Ventilator-Associated Pneumonia From the Centers for Disease Control and Prevention
Am. J. Crit. Care., January 1, 2007; 16(1): 28 - 37.
[Abstract] [Full Text] [PDF]

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 Proc. Natl. Acad. Sci. USAHome page
L. R. Hoffman, E. Deziel, D. A. D'Argenio, F. Lepine, J. Emerson, S. McNamara, R. L. Gibson, B. W. Ramsey, and S. I. Miller
Selection for Staphylococcus aureus small-colony variants due to growth in the presence of Pseudomonas aeruginosa
PNAS, December 26, 2006; 103(52): 19890 - 19895.
[Abstract] [Full Text] [PDF]

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 NEJMHome page
M. H. Kollef
Diagnosis of Ventilator-Associated Pneumonia
N. Engl. J. Med., December 21, 2006; 355(25): 2691 - 2693.
[Full Text] [PDF]

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 ChestHome page
F. Frutos-Vivar, N. D. Ferguson, A. Esteban, S. K. Epstein, Y. Arabi, C. Apezteguia, M. Gonzalez, N. S. Hill, S. Nava, G. D'Empaire, et al.
Risk Factors for Extubation Failure in Patients Following a Successful Spontaneous Breathing Trial
Chest, December 1, 2006; 130(6): 1664 - 1671.
[Abstract] [Full Text] [PDF]

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 Am. J. Physiol. Lung Cell. Mol. Physiol.Home page
C. E. O. Baleeiro, P. J. Christensen, S. B. Morris, M. P. Mendez, S. E. Wilcoxen, and R. Paine III
GM-CSF and the impaired pulmonary innate immune response following hyperoxic stress
Am J Physiol Lung Cell Mol Physiol, December 1, 2006; 291(6): L1246 - L1255.
[Abstract] [Full Text] [PDF]

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 Clin. Microbiol. Rev.Home page
S. M. Koenig and J. D. Truwit
Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention
Clin. Microbiol. Rev., October 1, 2006; 19(4): 637 - 657.
[Abstract] [Full Text] [PDF]

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 ChestHome page
M. N. Jeffres, W. Isakow, J. A. Doherty, P. S. McKinnon, D. J. Ritchie, S. T. Micek, and M. H. Kollef
Predictors of Mortality for Methicillin-Resistant Staphylococcus aureus Health-Care-Associated Pneumonia: Specific Evaluation of Vancomycin Pharmacokinetic Indices.
Chest, October 1, 2006; 130(4): 947 - 955.
[Abstract] [Full Text] [PDF]

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 Am. J. Respir. Crit. Care Med.Home page
C. Spies, V. Eggers, G. Szabo, A. Lau, V. von Dossow, H. Schoenfeld, H. Althoff, K. Hegenscheid, B. Bohm, T. Schroeder, et al.
Intervention at the Level of the Neuroendocrine-Immune Axis and Postoperative Pneumonia Rate in Long-term Alcoholics
Am. J. Respir. Crit. Care Med., August 15, 2006; 174(4): 408 - 414.
[Abstract] [Full Text] [PDF]

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 MicrobiologyHome page
F. R. Stirling and T. J. Evans
Effects of the type III secreted pseudomonal toxin ExoS in the yeast Saccharomyces cerevisiae.
Microbiology, August 1, 2006; 152(Pt 8): 2273 - 2285.
[Abstract] [Full Text] [PDF]

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 ChestHome page
I. Porzecanski and D. L. Bowton
Diagnosis and treatment of ventilator-associated pneumonia.
Chest, August 1, 2006; 130(2): 597 - 604.
[Abstract] [Full Text] [PDF]

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 Infect. Immun.Home page
A. Cuzick, F. R. Stirling, S. L. Lindsay, and T. J. Evans
The Type III Pseudomonal Exotoxin U Activates the c-Jun NH2-Terminal Kinase Pathway and Increases Human Epithelial Interleukin-8 Production
Infect. Immun., July 1, 2006; 74(7): 4104 - 4113.
[Abstract] [Full Text] [PDF]

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 J Intensive Care MedHome page
K. A. Davis
Ventilator-Associated Pneumonia: A Review
J Intensive Care Med, July 1, 2006; 21(4): 211 - 226.
[Abstract] [PDF]

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 Am. J. Respir. Crit. Care Med.Home page
D. E. Craven and R. A. Duncan
Preventing Ventilator-associated Pneumonia: Tiptoeing through a Minefield.
Am. J. Respir. Crit. Care Med., June 15, 2006; 173(12): 1297 - 1298.
[Full Text] [PDF]

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 Am. J. Respir. Crit. Care Med.Home page
M. Koeman, A. J. A. M. van der Ven, E. Hak, H. C. A. Joore, K. Kaasjager, A. G. A. de Smet, G. Ramsay, T. P. J. Dormans, L. P. H. J. Aarts, E. E. de Bel, et al.
Oral Decontamination with Chlorhexidine Reduces the Incidence of Ventilator-associated Pneumonia
Am. J. Respir. Crit. Care Med., June 15, 2006; 173(12): 1348 - 1355.
[Abstract] [Full Text] [PDF]

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 Am. J. Respir. Crit. Care Med.Home page
M. H. Kollef
Microbiological Diagnosis of Ventilator-associated Pneumonia: Using the Data to Optimize Clinical Outcomes.
Am. J. Respir. Crit. Care Med., June 1, 2006; 173(11): 1182 - 1184.
[Full Text] [PDF]

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 Am. J. Respir. Cell Mol. Bio.Home page
N. G. Hall, Y. Liu, J. M. Hickman-Davis, G. C. Davis, C. Myles, E. J. Andrews, S. Matalon, and J. D. Lang Jr.
Bactericidal Function of Alveolar Macrophages in Mechanically Ventilated Rabbits
Am. J. Respir. Cell Mol. Biol., June 1, 2006; 34(6): 719 - 726.
[Abstract] [Full Text] [PDF]

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 Am. J. Respir. Crit. Care Med.Home page
B. Afessa, R. D. Hubmayr, E. A. Vetter, M. T. Keegan, K. L. Swanson, L. M. Baddour, F. R. Cockerill III, and S. G. Peters
Bronchoscopy in Ventilator-associated Pneumonia: Agreement of Calibrated Loop and Serial Dilution
Am. J. Respir. Crit. Care Med., June 1, 2006; 173(11): 1229 - 1232.
[Abstract] [Full Text] [PDF]

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 Anesth. Analg.Home page
M. Sander, C. von Heymann, V. v. Dossow, C. Spaethe, W. F. Konertz, U. Jain, and C. D. Spies
Increased interleukin-6 after cardiac surgery predicts infection.
Anesth. Analg., June 1, 2006; 102(6): 1623 - 1629.
[Abstract] [Full Text] [PDF]

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 ChestHome page
M. H. Kollef, L. E. Morrow, M. S. Niederman, K. V. Leeper, A. Anzueto, L. Benz-Scott, and F. J. Rodino
Clinical Characteristics and Treatment Patterns Among Patients With Ventilator-Associated Pneumonia
Chest, May 1, 2006; 129(5): 1210 - 1218.
[Abstract] [Full Text] [PDF]

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 J. Immunol.Home page
R. T. Sadikot, H. Zeng, M. Joo, M. B. Everhart, T. P. Sherrill, B. Li, D.-s. Cheng, F. E. Yull, J. W. Christman, and T. S. Blackwell
Targeted Immunomodulation of the NF-{kappa}B Pathway in Airway Epithelium Impacts Host Defense against Pseudomonas aeruginosa.
J. Immunol., April 15, 2006; 176(8): 4923 - 4930.
[Abstract] [Full Text] [PDF]

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 Am. J. Respir. Crit. Care Med.Home page
C. Gregoretti, V. Squadrone, C. Fogliati, C. Olivieri, and P. Navalesi
Transtracheal Open Ventilation in Acute Respiratory Failure Secondary to Severe Chronic Obstructive Pulmonary Disease Exacerbation
Am. J. Respir. Crit. Care Med., April 15, 2006; 173(8): 877 - 881.
[Abstract] [Full Text] [PDF]

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 Postgrad. Med. J.Home page
J D Hunter
Ventilator associated pneumonia.
Postgrad. Med. J., March 1, 2006; 82(965): 172 - 178.
[Abstract] [Full Text] [PDF]

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 Eur Respir JHome page
E. Kostadima, A. Kaditis, E. Alexopoulos, E. Zakynthinos, and D. Sfyras
From the authors
Eur. Respir. J., February 1, 2006; 27(2): 437 - 438.
[Full Text] [PDF]


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