Inflammation and the Host Reponse to Injury, a Large-Scale Collaborative Project: Patient-Oriented Research Core—Standard Operating Procedures for Clinical Care II. Guidelines for Prevention, Diagnosis and Treatment of Ventilator-Associated Pneumonia (VAP) in the Trauma Patient

Ventilator-associated pneumonia (VAP*) is the most common nosocomial infection encountered in the ICU setting. Injured patients are particularly prone to VAP due in part to injuries such as direct chest trauma with pulmonary contusion and inability to control oropharyngeal secretions associated with traumatic brain injury. Post-injury immunosuppression is a recognized complicating factor of severe injury. Furthermore, common therapies used in caring for injured patients, such as blood transfusion, total parenteral nutrition and repeated trips to the operating room add to this immunocompromised state. The Centers for Disease Control (CDC), through the National Nosocomial Infections Surveillance System (NNIS), report that the median rate of VAP per 1000 ventilator days for patients in trauma ICU’s (11.4) was higher than any other individual type of surgical ICU (general surgery, cardiac surgery, neurosurgical, etc.). This rate was more than double that seen in medical (3.7) or coronary care (4.0) ICU’s. The mortality and morbidity attributable to VAP is difficult to ascertain. In a matched cohort study looking at a mixed population, the relative risk of death attributable to pneumonia was 32%. This increase was only significant in medical ICU patients where the relative risk of death attributable to pneumonia was 65%, suggesting an episode of VAP tips the balance for the medically frail. It is likely that surgical patients, by virtue of either being selected by surviving operative intervention (or their injuries) have adequate reserve such that an episode of VAP is less likely to be fatal. However, the additional length of stay (4–6 days) and associated costs, coupled with the detrimental effects of antimicrobial use on ICU ecology, calls for aggressive prevention strategies and a practical, evidence-based approach to managing VAP in critically ill trauma patients. Despite its common occurrence, there is still no agreed upon “gold standard” for the diagnosis of VAP and contro-