Hospital & Ventilator Pneumonia

• VAP prevention bundle: head-up 30–45°, daily SAT/SBT, subglottic secretion drainage (when available), oral care, DVT prophylaxis.
• Empiric therapy: antipseudomonal β-lactam (cefepime/pip-tazo/meropenem) ± an MRSA agent with risk factors; de-escalate by cultures.
• A 7-day course is typical; a negative MRSA nasal PCR lets you skip vancomycin.
• Aminoglycosides must NOT be monotherapy; inhaled colistin is an adjunct for MDR gram-negatives.

Step-by-Step Management of Nosocomial Pneumonia

• Nosocomial pneumonia suspected — first try to exclude noninfectious causes of the symptoms
• Send cultures (blood plus): protected specimen brush (PSB) · bronchoalveolar lavage (BAL) · tracheal aspirate · blind BAL or PSB
• Begin empiric antibiotics chosen by risk factors for likely pathogens
• Keep empiric therapy going 48 to 72 hours or until culture results are final
• Response?
• Symptoms improved or stable → deescalate therapy per culture results and antimicrobial susceptibility
• Symptoms resolved, cultures negative → consider stopping antibiotics
• Symptoms not improving → rule out complications (e.g., abscess, empyema) and noninfectious issues · reassess for an antibiotic-resistant pathogen missed by the initial antimicrobial regimen or inadequate antibiotic concentration in lung
• Ongoing improvement → cap antibiotics at 7 days for all pathogens including Pseudomonas (IDSA 2016)