Table 1 Decalogue to treat VAP caused by MRD pathogens

1

Antimicrobials used in the empirical regimens should be chosen based on the local pattern of susceptibility.

2

Initiation of antimicrobial therapy should not be delayed in patients with high probability of VAP especially if the infection originates severe sepsis or septic shock.

3

In patients with no signs of severe sepsis or septic shock and no organisms present on Gram’s staining, antimicrobial therapy can be withheld pending culture results.

4

When a high rate of episodes is caused by extremely resistant GNB, empirical use of colistin and/or tygecycline may be justified.

5

The inclusion of a carbapenem (in extended infusion) in this empirical therapy seems reasonable especially for pathogens not covered by these antibiotics.

6

Addition of vancomycin or linezolid is recommended is Units with high prevalence of MRSA (>10% of episodes caused by MRSA).

7

The initial antibiotic treatment must be reassessed when the culture results are available. Depending on the clinical progress and the microbiological findings, clinicians should adjust therapy accordingly.

8

In episodes caused by very-difficult-to-treat GNB, it seems prudent to maintain combination therapy (if possible) until the clinical course appears clearly favorable.

9

Nebulized antibiotics should be considered in the directed therapy of patients who are nonresponsive to systemic antibiotics or in episodes caused by GNB strains with high CMI (intermediate).

10

Not all patients with MDR-VAP have to be treated for two weeks. Courses of treatment should be individualized. Procalcitonin may be of aid to stop antibiotics after eight days of adequate antimicrobial therapy.