The research agenda in VAP/HAP: next steps

Excerpt

In the coming decade, ventilator-associated pneumonia (VAP) and hospital-acquired pneumonia (HAP) will continue to be major infections in the intensive care unit (ICU). While prevention efforts may reduce the frequency of these infections, we do not believe that “zero VAP”, which is a common goal in the USA, has or will be achieved, as evidenced by continued antibiotic use for nosocomial respiratory infections [1]. In Europe, the degree of preventable VAP has been estimated to be approximately 50%, so many episodes will still be present, in spite of the use of ventilator bundles [2]. In the coming decade, we anticipate the need for better epidemiologic and diagnostic tools that will inform us about the true incidence of these infections and the impact of specific prevention strategies. For epidemiologic purposes, the concept of ventilator-associated events (VAE), used by some in the USA, has not gained traction in Europe and it seems unlikely to become a valued concept [3]. Recently, a systematic review and meta-analysis examined 61,489 patients receiving mechanical ventilation in eight countries and found that the pooled sensitivity and positive predictive value of each VAE type for VAP detection did not exceed 50%, reflecting that VAE surveillance does not accurately detect cases of traditional VAP [3]. The clinical management and importance of the ventilator-associated lower respiratory tract infections (VA-LRTI) concept also need clarification. A multicentre, prospective, observational study found improved outcomes with the use of appropriate antibiotic treatment in VA-LRTI (including ventilator-associated tracheobronchitis, or VAT) [4]. Future studies are needed to see if VAT is an appropriate illness for routine antibiotic therapy, or whether only certain specific VAT needs antibiotic treatment. One area not covered by VA-LRTI is pneumonia in non-ventilated patients, and the topic of HAP requires more study to clarify its true incidence and bacteriology (possibly with quantitative culture methods) and to determine if the current assumptions, that the bacteriology parallels that of VAP, are in fact accurate. …