4
Treatment
Initial
Î In patients with ventilator-associated tracheobronchitis (VAT) ATS and
IDSA suggest NOT providing antibiotic therapy (W-L).
Î ATS and IDSA recommend that all hospitals regularly generate and
disseminate a local antibiogram, ideally one that is specific to their
intensive care population(s) if possible.
Î ATS and IDSA recommend that empiric treatment regimens be
informed by the local distribution of pathogens associated with VAP
and their antimicrobial susceptibilities.
Î In patients with suspected VAP, ATS and IDSA recommend including
coverage for S. aureus, Pseudomonas aeruginosa, and other Gram-
negative bacilli in all empiric regimens (S-L).
• ATS and IDSA suggest including an agent active against MRSA for the empiric
treatment of suspected VAP only in patients with any of the following : a risk
factor for antimicrobial resistance (Table 3), patients being treated in units where
10%–20% of S. aureus isolates are methicillin resistant, and patients in units where
the prevalence of MRSA is not known (W-VL).
• ATS and IDSA suggest including an agent active against methicillin-sensitive S.
aureus (MSSA) (and not MRSA) for the empiric treatment of suspected VAP in
patients without risk factors for antimicrobial resistance, who are being treated in
intensive care units (ICUs) where <10%–20% of S. aureus isolates are methicillin
resistant (W-VL).
Î If empiric coverage for MRSA is indicated, ATS and IDSA recommend
either vancomycin or linezolid (S-M).
Î When empiric treatment that includes coverage for MSSA (and not
MRSA) is indicated, ATS and IDSA suggest a regimen including
piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or
meropenem (W-VL).
• Oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven MSSA but
are not necessary for the empiric treatment of VAP if one of the above agents is used.
Î ATS and IDSA suggest prescribing two antipseudomonal antibiotics
from different classes for the empiric treatment of suspected VAP only
in patients with any of the following: a risk factor for antimicrobial
resistance (Table 3), patients in units where >10% of Gram-negative
isolates are resistant to an agent being considered for monotherapy,
and patients in an ICU where local antimicrobial susceptibility rates
are not available (W-L).
Î ATS and IDSA suggest prescribing one antibiotic active against P.
aeruginosa for the empiric treatment of suspected VAP in patients
without risk factors for antimicrobial resistance who are being treated
in ICUs where <10% of Gram-negative isolates are resistant to the
agent being considered for monotherapy (W-L).
