基于循证医学的VAP诊断治疗实践指南

David

Journal of Critical Care
Volume 23, Issue 1, March 2008, Pages 138-147

Theme Issue Editorial
Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Diagnosis and treatment
基于循证医学的VAP诊断治疗实践指南
John Muscedere MDa, Peter Dodek MD, MHScb, Sean Keenan MD, MScb, Rob Fowler MDCM, MSc, Deborah Cook MD, MScd, Daren Heyland MD, MSca, ,  and for the VAP Guidelines Committee and the Canadian Critical Care Trials Group1
aDepartment of Medicine, Queen’s University, Kingston, Canada K7L 2V7
bUniversity of British Columbia, British Columbia, Canada V6Z 1Y6
cUniversity of Toronto and Sunnybrook Health Sciences Center, Toronto, Canada M4N 3M5
dClinical Epidemiology and Biostatistics at McMaster University, Hamilton, Canada L8N 3Z5

Available online 20 March 2008.



Abstract
Background
Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in ventilated critically ill patients. Despite a large amount of research evidence, the optimal diagnostic and treatment strategies for VAP remain controversial.

Purpose
The aim of this study was to develop evidence-based clinical practice guidelines for the diagnosis and treatment of VAP. Data sources include Medline, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Database of Systematic Reviews and Register of Controlled Trials.

Study Selection
The authors systematically searched for all relevant randomized controlled trials and systematic reviews on the diagnosis and treatment of VAP in mechanically ventilated adults that were published from 1980 to October 1, 2006.

Data Extraction
Independently and in duplicate, the panel critically appraised each published trial. The effect size, confidence intervals, and homogeneity of the results were scored using predefined definitions. The full guideline development panel arrived at a consensus for scores on safety, feasibility, and economic issues.

Levels of Evidence
Based on the scores for each topic, the following statements of recommendation were used: recommend, consider, do not recommend, and no recommendation because of insufficient or conflicting evidence.

Data Synthesis
For the diagnosis of VAP in immunocompetent patients, we recommend that endotracheal aspirates with nonquantitative cultures be used as the initial diagnostic strategy. When there is a suspicion of VAP, we recommend empiric antimicrobial therapy (in contrast to delayed or culture directed therapy) and appropriate single agent antimicrobial therapy for each potential pathogen as empiric therapy for VAP. Choice of antibiotics should be based on patient factors and local resistance patterns. We recommend that an antibiotic discontinuation strategy be used in patients who are treated of suspected VAP. For patients who receive adequate initial antibiotic therapy, we recommend 8 days of antibiotic therapy. We do not recommend nebulized endotracheal tobramycin or intratracheal instillation of tobramycin for the treatment of VAP.

Conclusion
We present evidence-based recommendations for the diagnosis and treatment of VAP. Implementation of these recommendations into clinical practice may lessen the morbidity and mortality of patients who develop VAP.

Keywords: Ventilator-associated pneumonia; Clinical practice guidelines; Invasive technique; Noninvasive technique; Diagnosis; Treatment; Antibiotics