Ventilator-associated pneumonia: newer insights that can drive improved outcomes

Ventilator-associated pneumonia (VAP) results in substantial morbidity and results in high crude mortality rates. Many recent studies address multiple aspects of VAP ranging from its evolving epidemiology and microbiology to novel means for prevention and treatment.

The true incidence of VAP remains difficult to assess given definitional issues, which confound accurate diagnostic conclusions. The lack of a clear gold standard for identifying VAP makes comparisons across different studies difficult, as it remains unclear if like syndromes are actually being described. Nonetheless, VAP remains a clinical and costly challenge. Earlier discussion of achieving 'zero' VAP were clearly misplaced. Furthermore, the microbiology of VAP continues to evolve with the spread of antimicrobial resistance. New attention on the microbiome, though, may prove helpful and enhance our understanding of the pathogenesis of VAP. Simple interventions such a toothbrushing appear to successfully reduce rates of VAP and should be more broadly adopted. Rapid diagnostic tools, which are increasingly utilized to identify the causative pathogen in VAP, appear to have more limitations than previously thought. Several novel antibiotics are now available for treating multidrug-resistant organisms (MDROs) often encountered in VAP. With respect to antibiotic treatment more generally, it appears that shorter durations of therapy are well tolerated and effective, even in cases of VAP caused by MDROs.

Although our knowledge and understanding of VAP continues to advance, many of the general questions of the last decade remain unresolved. We continue to lack a clear and simple means for defining VAP and have yet to identify the optimal approach for prevention. Likewise, despite the availability of newer antimicrobials, we continue to lack rapid diagnostics that can clearly be shown to improve patient-centered endpoints. The availability of newer antibiotics may allow us to more easily and safely treat MDROs, but they have not revolutionized outcomes or been shown to reduce mortality.