The zero-VAP sophistry and controversies surrounding prevention of ventilator-associated pneumonia

Excerpt

In critically ill mechanically ventilated patients, ventilator-associated pneumonia (VAP) is the most common iatrogenic pulmonary infection. Diagnosis of VAP is challenging, potentially leading to delayed treatment or overuse of antimicrobials [1]. The impact of VAP on clinical outcomes has been thoroughly investigated [2], but remains a matter of controversy. Indeed, various trials that showed reduction of VAP failed to demonstrate improved clinical outcomes. In addition, the association between VAP and mortality is uncertain, since risk of VAP is time-dependent and patient needs to survive at least until VAP onset, limiting clear extrapolation of mortality risks. Studies attempting to control for these confounding biases have demonstrated VAP attributable mortality slightly higher than 10% [3]. Irrespective of methodological limitations, substantial body of evidence has been produced in this field and a questionable drive to achieve zero-VAP rates has grown in the past decade. This editorial provides a critical viewpoint on the zero-VAP contradiction, and summarizes controversies surrounding pharmacological and non-pharmacological interventions to reduce VAP rates. …