Guias Americanas de Ventilación Mecánica en QUEMADOS

PRACTICE GUIDELINES

American Burn Association Practice Guidelinesfor Prevention, Diagnosis, and Treatment ofVentilator-Associated Pneumonia (VAP)in Burn Patients

Michael J. Mosier, MD, Tam N. Pham, MD

The purpose of this guideline is to review the available published literature on ventilator-associated pneumonia (VAP) as it pertains to the burn patient. It provides an evidence-based recommendation for the prevention, diagnosis, and treatment of VAP in adultburn patients. This guideline is designed to assist all healthcare providers caring foradult burn patients with suspected VAP. Summary recommendations were made usingthe following grading scale: grade Asupported by at least one well-designed prospec-tive trial with clear-cut results; grade Bsupported by several small prospective trialswith a similar conclusion; and grade Csupported by a single small prospective trial,retrospective analyses, cases studies, and expert opinions based on investigators prac-tices. (J Burn Care Res 2009;30:910928)

RECOMMENDATIONS

StandardsThere are insufficient data to support a managementstandard ventilator-associated pneumonia (VAP) atthis time.

Guidelines Mechanically ventilated burn patients are at high

risk for developing VAP, with the presence ofinhalation injury as a unique risk factor in thispatient group.

VAP prevention strategies should be used inme-chanically ventilated burn patients.

Clinical diagnosis of VAP can be challenging inmechanically ventilated burn patients where sys-temic inflammation and acute lung injury areprevalent. Therefore, a quantitative strategy,

when available, is the preferable method to con-firm the diagnosis of VAP.

An 8-day course of targeted antibiotic therapy isgenerally sufficient to treat VAP; however, resis-tant Staphylococcus aureus and Gram-negativebacilli may require longer treatment duration.

OVERVIEW

PurposeThe purpose of this guideline is to review the availablepublished literature on VAP as it pertains to the burnpatient. It provides evidence-based recommenda-tions for the prevention, diagnosis, and treatment ofVAP in adult burn patients.

UsersThis guideline is designed to assist all healthcare provid-ers caring for adult burn patients with suspected VAP.

Clinical ProblemHospital-associated pneumonia is the second mostcommon nosocomial infection (most common infec-tion in mechanically ventilated patients) in theUnited States. Recent reviews indicate that between10 and 20% of patients receiving 48 hours of me-chanical ventilation will develop VAP. VAP has been

From the University of Washington Burn Center and Departmentof Surgery, Division of Burns/Trauma, Harborview MedicalCenter, Seattle, Washington.

Address correspondence to Tam N. Pham, MD, University ofWashington Burn Center, Harborview Medical Center, 325Ninth Avenue, Box 359796, Seattle, Washington 98104.

Copyright 2009 by the American Burn Association.1559-047X/2009

DOI: 10.1097/BCR.0b013e3181bfb68f

910

traditionally defined as an infection occurring 48hours after hospital admission in a mechanically ven-tilated patient with a tracheostomy or endotrachealtube.1 In early 2007, the Centers for Diseases Con-trol (CDC) revised their definition for diagnosingVAP.2 These latest criteria state that there is no min-imum period that the ventilator must be in place todiagnose VAP. Those who develop VAP are twice aslikely to die compared with similar patients withoutVAP, and patients with VAP have significantly longerintensive care lengths of stay, associated with an ad-ditional $40,000 in hospital charges.3,4

Injured patients have the highest risk of developingVAP of any individual hospital patient population.Reports from single center studies estimate the inci-dence of VAP as 22.1 to 26 per 1000 ventilator daysin burn patients.57 The National Nosocomial Infec-tions Surveillance System reports the median rate of11.4 VAP per 1000 ventilator days for patients intrauma intensive care units (ICUs), higher than sur-gical ICUs, and more than double that seen in med-ical (3.7) or coronary care ICUs (4.0).4,8 These dataare consistent with findings of a large Canadian studywhere burns had the highest relative risk of VAP (5.1,95% CI: 1.517.0), followed by trauma (5.0, 95% CI:1.913.1), compared with the medical ICU refer-ence group.9

Ultimately, improving ourmanagement of this dis-ease is not only medically important but also maycarry financial implications for burn centers in theUnited States. Despite multiple studies indicatingthat burn patients have unique risk factors for devel-oping VAPincluding inhalation injury, prolongedmechanical ventilation, and intensive care length ofstaythe Centers forMedicare andMedicaid servicesare considering cessation of reimbursements for ser-vices related to this potentially preventable complica-tion. In a letter to the Department of Health, theAmerican Burn Association has expressed strong con-cerns about the inclusion of VAP into the list ofhealthcare-associated infections because of the under-lyingnature of the admitting conditions inburnpatientsthat factor into the development of pneumonia.The following recommendations were developed

using burn-specific and general critical care literature,where appropriate, to assist providers in tailoring ap-proaches to the prevention, diagnosis, and treatmentof VAP with an understanding of pathogenesis, riskfactors, and challenges specific to the burn patient.

PROCESS

AMedline search of the English-language literature wasconducted for the years 1966 to 2008 for all publica-

tions involving the key words burns, thermal in-jury, and pneumonia, nosocomial, hospital-acquired, ventilator-associated/acquired, burnbacterial pneumonia, burn fungal pneumonia.Additional publicationswere retrievedby evaluating ref-erences from the available articles. They were collec-tively reviewed, and summary recommendations weremade using the following grading scale (Table 1): gradeAsupported by at least one well-designed prospectivetrial with clear-cut results; grade Bsupported by sev-eral small prospective trials with a similar conclusion;grade Csupported by a single small prospective trial,retrospective analyses, cases studies, and expert opinionsbased on investigators practices.

SCIENTIFIC FOUNDATION

VAP Pathogenesis and the Role ofInhalation InjuryVAP often results from microbial invasion of the nor-mally sterile lower respiratory tract and lung paren-chyma by aspiration, and less commonly from blood-stream spread or by direct extension of adjacentinfection. Principle defenses against infection in the hostinclude glottis closure, cough reflexes, mucociliaryclearance mechanisms, and immune cells-mediated re-sponses to eliminate infection. Comparison of bacterialDNA samples from broncheoalveolar lavages to organ-isms present onpatients tongues has demonstrated thatthe oropharynx is a potential reservoir for VAP.10 Be-cause oropharyngeal colonization is often present on

Table 1. Grading of scientific evidence*

Level of EvidenceRecommendation

Grade Level

Class I: large prospectiveclinical trial

Grade A: supported by at leastone large prospective clinicaltrial with clear-cut results

Class II: small prospectiveclinical trial (low power)

Grade B: supported by severalsmall prospective clinicaltrials that support a similarconclusion

Class III: retrospectiveanalytical study,contemporaneouscontrols

Grade C: supported by a singlesmall prospective trial,retrospective studies, andconsensus expert opinions

Class IV: retrospectiveanalytical study,historical controls

Class V: case series, expertopinions

* Adapted from Sackett DL. Rules of evidence and clinical recommenda-tions on the use of antithrombotic agents. Chest. 1989;95(Suppl):2545.

Journal of Burn Care & ResearchVolume 30, Number 6 Mosier and Pham 911

admission, or subsequently acquired in the ICU, thisrisk factor is ubiquitous in critically ill patients.11,12

The stomach and sinuses are potential reservoirs ofbacteria. The stomach often becomes colonized withGram-negative bacteria during critical illness, and en-teric Gram-negative bacteria are among the most fre-quent microorganisms isolated from cultures of pa-tients with VAP. The gastropulmonary hypothesispostulates that colonization of the stomach leads tocolonization of the lower respiratory tract from sus-tained microaspiration of contaminated oropharyn-geal or gastric secretions around the endotrachealtube cuff.13 After entry into the respiratory tract, in-fection can evolve in the setting of impaired host de-fenses, a challenge by a highly virulent pathogen, oran overwhelming inoculum.14,15

Intubation and mechanical ventilation negate manyof the normal respiratory tract defenses against infec-tion, bypassing the glottis barrier, with leakage of con-taminated secretions around the endotracheal tube cuff,and pooling into lower airways. The mechanically ven-tilated patient is unable to clear their own secretions, hasimpaired mucociliary clearance, and is subjected to re-peated inoculations despite suctioning.The cumulative incidence of VAP increases with

the duration of mechanical ventilation, with thehighest risk of VAP early, at an estimated incidenceof 3% per day during the first 5 days, decreasing to2% per day on days 5 to 10, and to 1% per day after10 days.9,16 By definition, early-onset VAP occurswithin the first 4 days, in which normal mouth floraor community-acquired pathogens typically predom-inate. In contrast, late-onset pneumonia (defined as 5days and beyond) is predominantly caused by multi-drug resistant (MDR) Gram-negative organisms andmethicillin-resistant S. aureus (MRSA).17 Identifiedpatient, injury, and intervention factors that predis-pose the mechanically ventilated patients to developVAP are summarized in Table 2.Burn injury is a strong predictor of VAP, and the

intubation process itself contributes to the risk of infec-tion. Multiple reports have documented the effect ofprehospital and emergency intubation in addition to thepresence of an endotracheal tube as contributing topneumonia.1822 Cutaneous thermal injury can alsocause pulmonary dysfunction.23,24 In patients withlarge burns (2530% TBSA), increased capillary per-meability occurs not only at the injured site but also inremote organ systems.2527 At 48 hours after injury,tumor necrosis factor, interleukin-6, and interleukin-8are elevated in the systemic circulation and at distantsites, including the lung. Furthermore, these perturba-tions are temporally correlated to impairment in lung

physiology and predict subsequent nosocomial lunginfection.28

Approximately 10 to 20% of burn patients are alsovictims of inhalation injury, and the incidence in-creases with increasing burn size.29 Inhalation injuryis an important predictor of prolonged ventilator de-pendence, increased length of hospitalization, anddeath.3033 Inhalation injury is differentiated into 3distinct types: 1) systemic injury by inhalation of poi-sonous substance (ie, carbon monoxide), 2) upperairway heat injury, and 3) lower airway chemical in-jury. Hot air causes thermal injury to the upper tractepithelium, whereas smoke particles can cause exten-sive injury to the lower respiratory epithelium andpulmonary parenchyma.34,35 After significant smokeinhalation, the ciliary function of the respiratory lin-ing ceases.36 Epithelial cells immediately separatefrom the basement membrane, and intracellularbonds are disrupted.36,37

As with edema in the burn wound, the local injuryto the mucosa of the airway initiates an inflammatorycascade, with edema formation and increased bloodflow to the respiratory tree.3841 Leakage of plasmaproteins from the pulmonary microvasculature intothe interstitial and alveolar spaces leads to exudateformation. These exudates congeal with neutrophilsand necrotic cellular debris to form fibrin casts, par-tially or fully obstructing the airways and causingbronchoconstriction.42,43 Release of the proteolyticenzymes and oxidants initiated by the acute inflam-

Table 2. Identified independent factors for ventilator-associated pneumonia9,22,244252

Host Factors Intervention Factors

Burns and trauma Mechanical ventilation 2 dSevere critical illness Re-intubationAge 60 yr Supine head positionAcute respiratory distresssyndrome

Paralytic agents, continuousintravenous sedation

Chronic obstructive pulmonarydisease

Positive end-expiratorypressure

Serum albumin 2.2 g/dL Frequent ventilator circuitchanges

Multiple organ dysfunction 4 units of blood productstransfused

Large-volume gastricaspiration

Histamine 2-blockers,antacids

Gastric colonization andelevated pH

Nasogastric tube

Upper respiratory tractcolonization

Prior antibiotic therapy

Sinusitis Transport out of the intensivecare unit

Journal of Burn Care & Research912 Mosier and Pham November/December 2009

matory response destroys the lung parenchyma andincreases the microvascular permeability, furtherpropagating edema formation and decreasing gas ex-change.41,4451 Surfactant is also diminished, result-ing in alveolar collapse and a decrease in lung com-pliance.40,52 At the molecular level, smoke inhalationinduces a massive influx of alveolar leukocytes that areprimed for an early, enhanced lipopolysaccharide-activated cytokine response compared with alveolarleukocytes isolated from cutaneous burn patients oruninjured controls.53

As a result, burn patients with inhalation injuryfrequently develop pulmonary complications, includ-ing reactive airway disease, acute respiratory distresssyndrome (ARDS), and pneumonia.54 VAP isthought to be a common complication of ARDS:between 34 and 70% of patients with ARDS developVAP.5560 At autopsy, as many as 73% of patientswith a premortem diagnosis of ARDS also have his-tological evidence of pneumonia.61 VAP concurrentwith ARDS is typically late onset, caused by resistantbacteria, and can be polymicrobial. VAP diagnosis inpatients with ARDS is often difficult because of thelack of specificity of clinical criteria alone to diagnoseVAP concurrent to ARDS, thus, bronchoscopic eval-uation has been used in many studies.5860,62,63

VAP Prevention StrategiesConsiderable efforts have been devoted in critical careresearch to VAP prevention, although relatively fewreports have focused specifically on burn patients.Nevertheless, many of these findings are applicable tothemechanically ventilated burn patient and form thebasis of our recommendations (Table 3).

Necessity and Duration of Mechanical Ventilation.Naturally, reducing the need for intubation and me-chanical ventilation is highly desirable, because thisprocess alone increases the risk of VAP 6-fold to 21-fold.22,64 Unnecessary intubations should beavoided, whereas necessary intubations should beperformed under controlled conditions as much aspossible, because an increased incidence of VAP hasbeen documented with field and emergency depart-ment intubations compared with the ICU setting.18

Furthermore, avoiding accidental tube dislodgementand emergency reintubation also decreases VAP inci-dence.22,65,66 Presence of a cuff leak over 10 to 15%has been suggested as a simple screening test to limitreintubation for laryngeal edema and postextubationstridor andmay be particularly useful in the burn patientwith extensive head and neck edema following burnresuscitation.However, the absenceof a cuff leak later inhospitalization is not necessarily a contraindication toremoval of the endotracheal tube.6770 Daily interrup-tion of sedation and weaning protocols are establishedstrategies to reduce the duration of mechanical ventila-tion in ICU patients.65,66,7175 Although very few burnpatientswere included in these studies, centers that haveadopted the practice of daily spontaneous breathing tri-als report an improvement in extubation rates withoutan increase in reintubation rates.74,7678 These strate-gies are applicable to mechanically ventilated burn pa-tients aswell.Thus,we recommenddaily interruptionofsedation and daily spontaneous breathing trial. Recom-mendation grade: A.Use of Specialized Endotracheal Tubes. Special-

ized endotracheal tubes that reduce the bacterial in-oculummay prove particularly beneficial in subsets of

Table 3. Recommended ventilator-associated pneumonia prevention strategies

StrategyLevel ofEvidence

Study PopulationSources References

Avoid unnecessary intubation and re-intubation Class I Medical, surgical, and trauma 1, 18, 22, 65, 66, 253Implement ventilator weaning and sedation protocols Class I Medical, surgical, and trauma 65, 66, 7178Use of specialized endotracheal tubes Class I Medical and surgical 89Topical oral antisepsis (eg, Chlorhexidine) Class I Medical, surgical, and trauma 11, 118123, 254Use oral route for endotracheal and gastric tubes Class II Medical, surgical, and trauma 255257Continuous suctioning of subglottic secretions Class I Medical and surgical 7984Semirecumbent patient positioning with enteral nutrition Class I Medical, surgical, and trauma 90, 9294, 99, 258Avoid unnecessary red blood cell transfusions Class I Medical, surgical, trauma,

and burns126130

Heat-moisture exchangers to reduce tubing condensate,emptying of tubing condensate, and avoidanceof unnecessary ventilator circuit changes

Class I Medical, surgical, and trauma 66, 136, 138140

Infection control measures and intensive care unit surveillance Class I Medical, surgical, trauma,and burns

1, 72, 135, 140, 253


patients who need prolonged mechanical ventilation.Tubes with continuous aspiration of subglottic secre-tions have reduced the incidence of early-onset VAPin several studies.7984 Silver impregnated endotra-cheal tubes are theoretically attractive because of thebroad-spectrum antimicrobial activity of silver85 andprevention of bacterial adhesion and biofilm forma-tion.8688 Use of a silver-coated endotracheal tubeswas recently evaluated in the NASCENT randomizedtrial of 9417 patients across 54 centers in NorthAmerica, showing a 35.9% relative risk reduction inVAP from an incidence of 7.5 to 4.8% in amixed ICUpopulation of patients expected to require intubationfor24 hours.89 At this time, we consider specializedendotracheal tubes an option in the management ofmechanically ventilated burn patients, until confirma-tory evidence supports their benefit in the burn pop-ulation. Recommendation grade: A.Reducing Aspiration From Gastrointestinal

Tract Sources. The supine position and simulta-neous administration of enteral nutrition are consid-ered risk factors for the development of VAP due toan increased risk of aspiration of gastric contents.90,91

Patients fed enterally in the supine position have asmuch as a 50% incidence of VAP compared to 5% inthose kept in the semirecumbent position.90,9294

Thus, we recommend maintaining mechanically ven-tilated burn patients in the semirecumbent position,especially when enterally fed. Recommendationgrade: A.Under fasting conditions, gastric sterility is main-

tained by an acidic pH. Clinical evidence suggeststhat a gastric pH of 3.5 prevents bacterial coloniza-tion, whereas a pH 4.0, potentiated by many com-mon ICU practices such as stress-ulcer prophylaxisand continuous enteral nutrition, is associated withclinically important bacterial colonization and ahigher incidence of nosocomial pneumonia in many,but not all reports.55,9598

Joint Commission on Accreditation of HealthcareOrganizations core measures currently mandatestress ulcer prophylaxis on ventilated patients; how-ever, with improvement in resuscitation and hemo-dynamic monitoring, clinically important stress gas-tritis is now a rare event in the burn ICU. Early andaggressive enteral nutrition is also likely to providesome level of protection against stress gastritis and islikely to be partly responsible for the significantly de-creased incidence of gastric ulceration in burn pa-tients; however, although gastric feeds may offer adegree of protection against stress gastritis, duodenalfeedsmay not. Thus, a conflict exists between increas-ing gastric pH to decrease the risk for stress gastritis

and increasing colonization of the upper gastrointes-tinal tract with risk of aspiration of bacteria.Further support for the gastropulmonary hypoth-

esis comes from scintigraphic imaging studies, docu-menting that patients fed into the stomach have moreepisodes of gastroesophageal regurgitation and trendtoward more microaspiration compared with patientsfed beyond the pylorus; and patients with gastro-esophageal regurgitation are more likely to aspiratethan patients without.99 Three randomized con-trolled trials comparing gastric with postpyloric en-teral feeding found an 8 to 15% absolute reduction inVAP with postpyloric feeding. Unfortunately, theylacked sufficient power to show a statistical signifi-cance.100 Thus, until a sufficiently powered study isperformed, a postpyloric feeding tube remains an op-tion in mechanically ventilated burn patients receiv-ing enteral nutrition and should be attempted if pos-sible, given the improved tolerance and potentialdecreased incidence of VAP. However, if logisticallyrestrictive, enteral feedings should not be delayedwhile awaiting placement of a postpyloric feedingtube. In addition, until there is better evidence aboutthe risk of stress gastritis with postpyloric feeding incritically sick patients, if a patient is fed postpyloricand remains mechanically ventilated or coagulo-pathic, pharmacologic stress ulcer prophylaxis shouldlikely be used to decrease the risk of clinically signif-icant gastrointestinal bleeding. Recommendationgrade: A.Role of Prophylactic Antibiotic Administration.

Modulation of oropharyngeal colonization by com-binations of oral antibiotics, with or without systemictherapy, or by selective decontamination of the gas-trointestinal tract (SDD) has also been shown to re-duce the frequency of VAP.101104 Fifty-eight ran-domized controlled trials and 12 meta-analyses havebeen published focusing on SDD. The meta-analyseshave consistently demonstrated a significant reduc-tion in pneumonia.105 The largest Cochrane meta-analysis, including 6922 patients, indicated that SDDusing parenteral and enteral antimicrobials reducedthe odds ratio (OR) for pneumonia to 0.35 (95% CI:0.290.41), with similar results in trauma patients(OR: 0.38; 95% CI: 0.290.50).106 SDD has alsoshown a survival benefit in all meta-analyses includingparenteral and enteral antimicrobials (OR: 0.78; 95%CI: 0.680.89), which shows that one life can besaved for every 21 patients treated.SDD has been investigated in a few trials looking

specifically at burn patients. A study from ShrinersHospitals for Children, Galveston, examined a smallnumber of severely burned pediatric patients andfound no difference in pneumonia, sepsis, or mortal-


ity with SDD.107 In contrast, a much larger Spanishrandomized, placebo-controlled, double-blind trialfound a mortality reduction from 27.8 to 9.4% withSDD in the burn ICU.108

Similar to SDD is the idea of prophylactic antibi-otics to decrease the incidence of VAP in areas wherethe incidence is unacceptably high. In Japan, 57% ofS. aureus strains isolated from all the national hospi-tals are identified asMRSA, a percentage that is muchhigher than any other country. This high incidenceand the increased risk inherent to patients with largerburn size led Kimura et al at the Nippon MedicalSchool Hospital to undergo a prospective, random-ized, placebo-controlled study of trimethoprim-sulfamethoxazole (TMP-SMX) in patients with burns20%TBSA. In 40 enrolled patients, the incidence ofMRSA pneumonia was 4.8% in the TMP-SMX groupand 36.8% in the placebo group, a statistically signif-icant difference. Notably, no major side effects oftherapy with TMP-SMX were observed, and therewas no increased resistance to TMP-SMX. Their re-sults combined with SDD, which typically targetsGram-negative organisms, suggest a significant po-tential reduction in the incidence of VAP in severelyburned patients.109

Unfortunately, the preventive benefits of prophy-lactic antibiotics for VAP have been considerablylower in ICUs with high endemic levels of antibioticresistance.110116 In this setting, SDD seemed to in-crease the selective pressure for antibiotic-resistantmicroorganisms that are likely to occur in burn pa-tients with high colonization and infection rates.114

Thus, despite positive reviews of the many random-ized clinical trials and meta-analyses that have influ-enced European practice,117 critical care (includingburn) providers in the United States have been reluc-tant to adopt prophylactic antibiotics for these rea-sons, arguing that the benefits derived by reducingearly-onset VAP episodes are outweighed by this an-tibiotic selection pressure. Therefore, although pro-phylactic antibiotics reduce early-onset VAP, routineprophylactic use of antibiotics should be discouragedin hospital settings where there are high levels of an-tibiotic resistance. Recommendation grade: A.Decreasing Oropharyngeal Bacterial Colonization.

Chlorhexidine oral rinse has been shown in many stud-ies to be a simple and cost-effective prevention strategyfor VAP in many different patient populations. DiRisoet als11 prospective, randomized, double-blind trial incoronary artery bypass graft patients showed a 69% re-duction in the incidence of respiratory infections withno change in antibiotic resistance patterns. Similarly,Houston et al118 found a 58% reduction in pneumoniain patients intubated 24 hours. Benefits have also

been shown in critically ill medicine patients venti-lated 48 hours, with a 65% reduction in VAP.119

Meta-analysis has further supported the finding that oralantisepsis decreases the incidence of VAP.120122 Onthe other hand, the PIRAD study groups multicenterdouble-blind, placebo-controlled study found that al-though antiseptic decontamination significantly de-creased oropharyngeal colonization of aerobic patho-gens in ventilated patients, its efficacy was insufficient toreduce the incidence of respiratory infections caused bymultiresistant bacteria.123 Given that many trials indi-cate a VAP reductionwith this strategy, we recommendoral chlorhexidine to decrease oropharyngeal coloniza-tion as an effective VAP prevention strategy. Recom-mendation grade: A.Practice of Restrictive Blood Transfusion.

Postinjury immunosuppression is a recognized com-plication of severe burn injury, and common thera-pies used in caring for injured patients, such as bloodtransfusion, add to the immune compromisedstate.124,125 In a multicenter, prospective observa-tional study of 1518 patients receiving mechanicalventilation for 48 hours in 284 mixed-ICUs acrossthe U.S., Shorr et al126 established that transfusionindependently increased the risk for VAP (OR: 1.89;95% CI: 1.332.68) and that the effect of transfusionon late-onset VAP (defined as arising5 days of me-chanical ventilation) was more pronounced (OR:2.16; 95% CI: 1.273.66).The American Burn Association Burn Multicenter

Trials group has examined the effect of blood trans-fusion in 666 patients at 21 burn centers with acuteburn injuries20% TBSA and found a 13% increasedrisk of infection with each unit of blood transfused.VAP occurred in 42% of those transfused and only in6% of those who did not receive a blood transfusion,although patients in the latter group were much lessseverely ill.127 In addition, a number of retrospectiveclinical studies have documented adverse outcomeassociations, including higher VAP incidence, withallogeneic blood transfusion and prolonged storagetimes.128130 Therefore, a restrictive transfusion pol-icy in mechanically ventilated burn patients reducesinfections and should be applied to burn patients.Recommendation grade: C.Intensive Insulin Therapy. Intensive insulin ther-

apy to control blood glucose levels (to levels 80110mg/dL) reduced mortality in surgical ICU patientsin a landmark trial published in 2001,131 but thiseffect was not confirmed in subsequent trials.132,133

These subsequent studies have also raised the issue ofhypoglycemia during intensive insulin therapy, whichmay negate its benefit in critically ill patients. Arabiet als132 study of medical and surgical ICU patients


found hypoglycemia occurred more frequently withintensive insulin therapy (goal of 80110 mg/dL)compared with conventional therapy (goal of 180200 mg/dL) at 28.6 vs 3.1%, with no difference inany other secondary outcomes. Similarly, Brunkhorstet als133 study of patients with severe sepsis showed asignificantly higher rate of severe hypoglycemia (40mg/dL) in the intensive insulin therapy group (17.0vs 4.1%), with a higher rate of serious adverse events(10.9 vs 5.2%). There have been few such studies inburns; however, Hemmila et al recently evaluatedtheir experience with intensive insulin therapy in burnpatients. Their adoption of an intensive insulin ther-apy protocol (140 mg/dL) did not have an impacton mortality, although it did decreased VAP rate.134

The potential benefit of intensive insulin therapy inburn patients needs to be confirmed in large prospec-tive trials before a formal recommendation can bemade in burn patients. At this time, implementationof an intensive insulin protocol constitutes an optioninmechanically ventilated burn patients. Recommen-dation grade: C.Environmental Infection Control Practices.

The environment, healthcare devices, and staff can allserve as sources of infection.1,135 Colonization of theventilator circuit may also lead to VAP.66 Many pro-spective, randomized trials have shown that the fre-quency of ventilator circuit changes does not affectthe incidence of VAP,136,137 but condensate collect-ing in the circuit can become contaminated frompatient secretions and be introduced into the lowerairway with position changes.138 Passive humidifiersor heat exchangers decrease ventilator circuit coloni-zation but have not significantly reduced the inci-dence of VAP.139,140 Recently, the U.S. military hasbeen able to significantly decrease their incidence ofVAP in Iraq with institution of an aggressive infectioncontrol protocol that has included hand hygiene,contact barrier precautions, patient and staff cohort-ing, chlorhexidine oral care, and reducing the dura-tion and spectrum of surgical antimicrobial prophy-laxis. Institution of their protocol decreased theincidence of VAP from a high of 60.6 per 1000 ven-tilator days to a low of 9.7 per 1000 ventilatordays.141We recommend the inclusion of infection con-trol measures as part of standard VAP prevention mea-sures in the burn ICU. Recommendation grade: A.Prevention Protocols (Known as Bundles). The

creation of the Leapfrog group in 2000 aimed toreduce preventable medical errors and to improve thequality and affordability of healthcare by encouraginghealth providers to publicly report their quality andoutcomes so that consumers and purchasing organi-zations can make informed healthcare choices. Pres-

ident George W. Bush issued an executive order inAugust 2006 to increase healthcare transparency byencouraging the adoption of health information tech-nology standards, the provision of options that pro-mote quality and efficiency in health, and the pricingand quality information be made publicly available.These and other actions have dramatically increasedthe pressure to initiate patient safety measures at in-dividual hospitals and to publicly report process ofcare and hospital outcomes, including complications.Given these regulatory pressures and the recog-

nized poor adherence to evidence-based best practicein the ICU setting, ventilator bundles were devel-oped to reduce associated complications. Bonello etal142 demonstrated a positive impact with such anapproach, with an increase in ventilator bundle com-pliance from 50 to 82% by the last 3 months of thestudy and a decrease in the incidence of VAP from11.7 to 6.9 events per 1000 ventilator days, a 41%reduction. Similarly, a Quality Rounds Checklisthas helped DuBose et al143 to improve their adher-ence with VAP prevention measures, such as head ofbed elevation 30 degrees, daily interruption of se-dation, peptic ulcer disease prophylaxis, and deep ve-nous thrombosis prophylaxis, and to decrease theirincidence of VAP from 16.3 to 8.9 events per 1000ventilator days.In contrast, Ogaard et al at Regions Burn Center

examined the impact of ventilator bundles on VAPincidence over 2 years. The Institute for HealthcareImprovement ventilator bundle consisted of four el-ements: elevation of the head of the bed between 30and 45 degrees, daily sedation vacation and daily as-sessment of readiness to extubate, peptic ulcer pro-phylaxis, and deep venous thrombosis prophylaxis.VAP incidence of 6.3 per 1000 ventilator days in thefirst year was reduced to 2.8 per 1000 ventilator daysin the second year. Mean monthly compliance of theVAP bundle was 59 and 78% for the first and secondyears, respectively. Overall compliance for monthswith and without VAP was 69%, thus, with the in-complete compliance rate and the already low inci-dence of VAP, they could not demonstrate an impactin their VAP rate with the use of the Institute forHealthcare Improvement VAP bundle.144 However,their burn center had a lower VAP rate than thepooled mean of the 12 burn centers nationwide re-porting to the National Nosocomial Infections Sur-veillance System in 2006.Thus, improved and continued reporting of data

from burn centers nationwide is essential to under-stand VAP occurrences. Despite enormous regula-tory pressures and data from nonburn ICUs indicat-ing its benefits, ventilator bundle implementation has


not yet been confirmed of benefit in burn patients. Assuch, this strategy of prevention of bundles remainsan option until further data becomes available. Rec-ommendation grade: C.

Diagnosis of VAPDespite its common occurrence, no clinical goldstandard exists for the diagnosis of VAP. The Cana-dian Critical Care Society, the American Thoracic So-ciety, and Infectious Disease Society of America havecreated guidelines for the prevention and manage-ment of VAP145; however, establishing the diagnosisof VAP can be particularly difficult in the burn patientwhere other causes of pulmonary dysfunction (inha-lation injury, systemic inflammation, and pulmonaryedema) not only predispose the patient to postinjurypneumonia but also may obscure its diagnosis. Tra-ditionally, VAP is suspected if the patient has clinicalfindings suggesting infection, including fever, puru-lent sputum, leukocytosis or leukopenia, and declinein oxygenation along with a new or progressive infil-trate on chest radiograph. Unfortunately, no consen-sus exists on which combination of findings yields anaccurate diagnosis of VAP,14,146,147 and many pa-tients with the clinical diagnosis of pneumonia mayhave noninfectious etiologies for their clinical find-ings, such that as many as 66% of patients with theclinical diagnosis of VAPmay notmeet microbiologiccriteria for infection.148

Efforts to improve our ability to diagnose VAPhave led to scoring systems such as the CDC Criteriaand the Clinical Pulmonary Infection Score (CPIS),which combine clinical, radiographic, physiologic(PaO2/FiO2), and microbiologic data, to improvethe specificity of VAP diagnosis.149,150 An initialscore 6 and a persistently elevated CPIS 6 after 3days of empiric treatment are strongly associated withVAP in medical and mixed ICU patients.149,150

Application of a clinical strategy such as CPIS toinjured patients is limited by common findings offever, leukocytosis, and the presence of ARDS in thispatient population. Two retrospective studies intrauma and burns have pointed to the presence ofsystemic inflammation and coexisting pulmonary dys-function as potential limitations to the utility ofCPIS,151153 and one larger study from France sug-gests that a strategy based on the CPIS to decide thatwhich patients with suspected VAP should receiveprolonged administration of antibiotics would seemto overprescribe these agents, when compared with astrategy based on bronchoscopy.154 These studieshighlight the fact that injured patients, whether fromtrauma, cutaneous burn, or smoke inhalation, havenumerous reasons for exhibiting an inflammatory re-

sponse. The CPIS scale is not able to differentiateinflammation from infection, a differentiation thatcan be definitively made by quantitative culture.In contrast to the clinical strategy, the bacteriologic

approach is used to obtain a lower airway quantitativeculture when VAP is suspected, using broncheoal-volar lavage (BAL), protected specimen brush, or anonbronchoscopic technique (so-called mini-BAL).The advantages of the quantitative strategy are theincreased specificity of diagnosis and the clear-cutidentification of responsible organisms, which mayreduce the extended use of broad-spectrum antimi-crobials in the ICU.14,63,145,147,155159 Limitationsinclude the limited availability of these diagnostictechniques and the potential for introducing infec-tion into lower airways with an invasive procedure.Furthermore, some patients may be too severely ill totolerate lower airway intubation and sampling be-cause of hypoxemia and shock. An additional point ofdisagreement exists as to the appropriate thresholdfor positivity in injured patients. Most authors use104 cfu/mL for BAL and 103 cfu/mL for protectedspecimen brush 160162; however, several studies inthe trauma population have used a BAL threshold of105 cfu/mL to limit unnessary administration of sys-temic antibiotics and demonstrated similar rates of VAPrecurrence.153,163,164 BAL should not be thought of as100% accurate in capturing the offending organisms, ashas been shownon lung biopsy,165 but does showgoodcorrelation,166,167 and many clinicians place a greatervalue in their culture results compared to with endotra-cheal aspirate and are more likely to de-escalate antibi-otic therapy.14,147

Comparison of clinical and bacteriologic strategiesin mixed ICU populations has yielded inconsistentresults.146,157 Patients who underwent quantitativeculture in a French multicenter randomized trial hadreduced mortality at day 14 (16.2 and 25.8%, P .022), decreased sepsis-related organ failure assess-ment scores at day 3 and day 7, and decreased anti-biotic use (P .001).157 In contrast, the CanadianCritical Care Trials Groups146 study showed similaroutcomes and overall use of antibiotics with quanti-tative culture vs endotracheal aspirate and nonquan-titative culture; however, this study has been criti-cized for its many limitations that influence itsresults.147,156,168

As part of the Inflammation and the Host Re-sponse to Injury research program, the investigatorsevaluated existing evidence-based data and guidelinesfor prevention, diagnosis, and treatment of VAP anddeveloped a standard operating procedure to unifymanagement of patients with suspected pneumonia.The protocol states as follows: clinical findings con-


sistent with pneumonia should lead to a quantitativerespiratory specimen culture and a Gram stain. Achest film should be used to document radiographicevidence of pneumonia. Empiric therapy may bestarted and should be based on local burn center andpatient-specific flora and resistance patterns. Culturesshould be obtained before initiating empiric therapyif possible. Antibiotics should be adjusted based onculture-based sensitivity and resistance patterns de-termined locally.160 We recommend that, when fea-sible, a bacteriologic strategy using quantitative lowerairway cultures is preferred to confirmVAP diagnosis.Recommendation grade: B.

TreatmentEarly-onset pneumonia, defined as being within thefirst 4 days, usually carries a better prognosis and ismore likely to be caused by antibiotic sensitive bacte-ria. Patients with inhalation injury are at particularlyhigh risk for early-onset VAP. A recent study byMosier et al169 documented that 16% of diagnosticBAL on admission grew 100,000 cfu/mL of pre-dominantly community-acquired organisms. Strepto-coccus pneumoniae and Haemophilus influenzae aremore typical of early-onset VAP in patients withoutother risk factors. At present, many strains of S.pneumoniae are penicillin resistant because of al-tered penicillin-binding proteins. Some suchstrains are resistant to cephalosporins, macrolides,tetracyclines, and clindamycin.170

In contrast, late-onset VAP is most commonlycaused by aerobic Gram-negative bacilli such asPseudomonas aeruginosa, E. coli, Klebsiella sp., andAcinetobacter, as well as MRSA. Carter et al con-firmed this finding in burn patients as well; in theirretrospective review, MRSA surveillance culture pos-itivity predicted the occurrence of MRSA VAP. Inaddition, all patients who developed MDR VAP didso after 7 days of mechanical ventilation.171

Significant growth of oropharyngeal flora (Streptococ-cus viridans, coagulase-negative staphylococci,Neisseria,and Corynebacterium) from distal bronchial specimenscan be difficult to interpret but can produce infection inimmunocompromised hosts and some immunocompe-tent patients.172 Rates of polymicrobial infection varywidely, but seem to be increasing, and are especiallyhigh in patients with ARDS.14,22 P. aeruginosa is themost commonMDRGram-negative pathogen causingVAP and has intrinsic resistance to many antimicrobialagents.173 Klebsiella, Enterobacter, and Serratia are in-trinsically resistant to ampicillin and other aminopeni-cillins and can acquire resistance to cephalosporins andaztreonam by the production of extended-spectrumbeta-lactamases.174176

Reviews from individual burn units now identifyAcinetobacter baumannii as a common infectious or-ganism in many burn units worldwide.177 Acineto-bacter species, although typically less virulent than P.aeruginosa, have become problematic pathogens be-cause of increasing antibiotic resistance. Acineto-bacter isolates are typically highly multiresistant, withmany distinct strains, and is more common in tropicalwarm climates or during summer months. More than85% of isolates are susceptible to carbapenems, butresistance is increasing because of either metaloen-zymes or carbapenemases. An alternative therapy issulbactam, usually used as an enzyme inhibitor, butwith direct antibacterial activity againstAcinetobacterspecies.176

In the United States, nearly 60% of the ICU infec-tions caused by S. aureus are with MRSA. Patientswith MRSA VAP are often older, have higher diseaseseverity scores, and have been on mechanical ventila-tion longer at onset of VAP.178 Many important vir-ulence factors exist with MRSA, including strainsbearing the Panton-Valentine leukocidin gene,179

which is associated with severe necrotizing VAP re-sulting in tissue destruction, cavitation, hemoptysis,and increased mortality.180 Although vancomycin in-termediate sensitivity and resistance are emerging, allisolates causing respiratory tract infections havefortunately been sensitive to linezolid.181,182 Un-fortunately, linezolid resistance has also emerged inS. aureus but is currently rare.183 Successful treat-ment of MRSA VAP with vancomycin may be low,ranging from only 35 to 57% as this agent has poorlung penetration.184

Nosocomial pneumonia caused by fungi such asCandida andAspergillus fumigatus, may occur in or-gan transplant or immunocompromised, neutropenicpatients, but is uncommon in immunocompetent pa-tients. Isolation of Candida albicans and other spe-cies from endotracheal aspirates is common, but usu-ally represents colonization of the airways, rather thanpneumonia in immunocompetent patients, and rarelyrequires treatment with antifungals.185189 However,patients with severe burns should be considered im-munocompromised, and burn patients have beencited as being among the highest risk groups for in-vasive fungal infections. Burn wounds provide anideal portal for invasive infection while inducing sub-stantial immune dysfunction. Fungal organisms arenow among the most common causes of burn woundinfection, with increasing risk as burn size increasesand with delay in excision of the burn wound.Early Initiation of Broad-Spectrum Antibiotic

Coverage. Whether VAP is early or late in onset,multiple studies have shown that a delay in the initi-


ation of appropriate antibiotic therapy for patientswith VAP is associated with increased morbidity, costof care, and mortality.159,190195 Therefore, once apatient is diagnosed with VAP, broad-spectrum anti-biotic therapy should begin immediately targetingspecific likely pathogens based on timing of VAP on-set and modified by knowledge of local patterns ofantibiotic resistance.159,196201 Choice of antibioticsshould not be guided by Gram stain because multiplestudies have shown poor correlation between Gramstain and final culture results.161,202204 Similarly, tra-cheal aspirates and sputum cultures do not accuratelyreflect presence or absence of infectious organisms inthe lower airways because the upper airway and en-dotracheal tube are rapidly colonized.14,205210 Im-portantly, a quantitative culture should be obtainedbefore initiation of antibiotics, if possible, and diag-nostic threshold should be lowered if the culture isobtained after administration of antibiotics.211214

Thus, we recommend that broad-spectrum antibiotictherapy begin immediately targeting specific likelypathogens based on timing of VAP onset and modi-fied by knowledge of local patterns of antibiotic re-sistance, following attainment of a quantitative cul-ture. Recommendation grade: C.De-Escalation of Broad-Spectrum Antibiotic

Coverage. If quantitative culture was obtained, nar-rowing the antimicrobial spectrum using microbio-logic results and sensitivities, known as de-escalationis most appropriate. This is an important concept andbenefit of a quantitative culture approach, becausethe incidence of MDR bacteria continues to rise,215,216

whereas our arsenal of antibiotics is limited, and a clin-ical strategy does not permit safe antibiotic therapy de-escalation. Use of an ICU-specific, broad-spectrum,empiric therapy regimen can lead to a significantincrease in the administration of appropriate anti-microbial treatment, a decrease in the developmentof secondary episodes of antibiotic-resistant VAP,and a significant reduction in the total duration ofantimicrobial treatment.197200,214 In addition, arecent international consensus conference agreedthat the use of broad-spectrum antibiotics for 48hours would not induce a significant risk ofMDR.217 Thus, we recommend de-escalation ofbroad-spectrum antibiotic coverage once quantita-tive culture results are known. Recommendationgrade: C.ICU-Specific Antibiotic Rotation Protocol. Al-

though no study has specifically examined its role inburns, antibiotic rotation has been evaluated andadopted bymany intensivists. Retrospective evaluationsandthree largeprospectiveevaluations inmedical, surgical,and trauma ICU patients have indicated a decreased inci-

denceofMDRbacteria andpossiblemortalitybenefitwithan antibiotic rotation protocol.199,200,218220 Knowledgeof local antibiotic resistance patterns should be consideredwhen choosing empiric antibiotics; however, antibioticrotation should be considered an option for individualburn centers to reduce the spread ofMDRbacteria untilfurther burn unit specific data become available. Thesestrategies should be tailored to the sensitivity and resis-tance patterns observed in individual burn centers. Rec-ommendation grade: A.Duration of Antibiotic Treatment.No study has

specifically addressed length of antibiotic treatmentfor VAP in burn patients; however, recent data fromother trials suggest that antibiotics can be stoppedonce clinical signs of infection have resolved. Thismay also decrease the incidence of secondary pneu-monias with MDR organisms.Micek et al221 showed that an antibiotic discontin-

uation policy based on a predefined clinical responseto antimicrobial therapy was associated with a shorterduration of antibiotic use and no difference in theoccurrence of secondary VAP episodes when com-pared with conventional antibiotic management.Mueller et al have used repeat BAL to guide antibioticduration. In their pilot study of 52 patients, antibiotictherapy was discontinued if bacterial growth droppedto10,000 cfu on repeat BAL performed on day 4 ofantibiotic therapy. Their results showed no differencein pneumonia relapse, ventilator-free ICU days, ICUdays, or mortality, but it did show a significant reduc-tion in the duration of antibiotic therapy at a mean of9.8 3.8 days vs 16.7 7.4 days, suggesting thatantibiotic duration for VAP can generally be shorterthan 2weeks.222Dennesen et al223 have reported thatmost of the clinical signs of pneumonia have resolvedby 6 days of therapy, and a recent multicenter ran-domized trial in France demonstrated no differencein mortality or recurrent infection in patients treatedwith an 8-day course of antibiotics compared withthose treated with a 15-day course. In addition, thosetreated with 8 days of antibiotics had a lower inci-dence of multiresistant pathogens if a recurrent infec-tion developed. Notably, if the original infecting or-ganism was a nonlactose fermenting Gram-negativebacilli such as P. aeruginosa or Acinetobacter bauma-nii, those treated with an 8-day course had a higherpulmonary infection recurrence rate.224 No differ-ence was noted in secondary outcomesmortality at28 and 60 days, number of organ failure-free days,number of ventilator-free days, length of ICU stay,and unfavorable outcome ratein patients with VAPcaused by nonlactose fermenting Gram-negative ba-cilli treated for 8 vs 15 days. Similar to the increasedvirulence of nonlactose fermenting Gram-negative


bacilli, MRSA pneumonias (particularly with thePanton-Valentine leukocidin gene and difficultiesin achieving appropriate antibiotic treatment) areoften quite virulent, with demands for longer ven-tilator and ICU support.179,180,225227 Therefore, werecommend limiting antibiotic treatment to 8 daysfor VAP, unless caused by MRSA or nonlactose fer-menting Gram-negative rods, in which case we rec-ommend treatment be continued for 15 days. Rec-ommendation grade: A.

Areas of Uncertainty and InvestigationProtocolized Management of Inhalation Injury.

The significant pulmonary dysfunction that accom-panies inhalation injury has led to multiple ap-proaches to mechanical ventilation. Volume control,synchronized intermittent mandatory ventilation andpressure support, pressure control to reverse inspira-tory to expiratory ratios, permissive hypercapnia, andhigh-frequency ventilation are all currently practiced.Despite all these options, well-controlled clinical tri-als defining the optimal mode of ventilation for adultswith inhalation injury have yet to be performed. Al-ternative modes of mechanical ventilation have beenexplored, and their benefits also need to be tested inrigorous trials. One method that has been studied inseveral studies is high-frequency percussive ventila-tion (HFV). Cioffi et al228 reported a 20% decreasedincidence of pneumonia compared with that in his-torical controls, indicating the importance of smallairway patency in the pathogenesis of inhalation in-jury sequelae and supporting further use and evalua-tion of HFV. Correlative evaluation of HFV inbaboons indicated that the prophylactic use of high-frequency ventilation significantly reduces ventilator-induced pulmonary damage and may explain the de-creased mortality in inhalation injury patients treatedwith HFV.229

Role of Tracheostomy in VAP Prevention. An-other unanswered question is the role of tracheos-tomy in burn patients. Multiple studies have tried toanswer the question of whether early tracheostomy isbeneficial to patients. Saffle et als230 randomized trialof 44 adult patients showed no difference in ventila-tor support, incidence of pneumonia, or survival with

early tracheostomy. Similarly, Barret et als231 reviewof 290 children revealed no difference in the inci-dence of pneumonia in patients with tracheostomiesvs endotracheal tubes. The debate over tracheostomycompared with translaryngeal intubation remains un-resolved. For any benefit of tracheostomy to be real-ized, this procedure should be done early in the pa-tients course. However, predictors of successfulventilator weaning are often inaccurate, and trache-ostomy can be a morbid procedure in the setting ofmassive tissue edema. Recently, percutaneous trache-ostomy has been demonstrated as a safe alternativeprocedure and may have a lower incidence of pneu-monia and complications, when compared with opentracheostomy.232

Promising Diagnostic Approaches. A number ofbiomarkers have been evaluated with the hope to bet-ter identify patients with VAP. Promising earlier ob-servational studies with procalcitonin led investigatorsto study procalcitonin and C-reactive protein levels inserum and BAL fluid to try to predict or assist in thediagnosis of VAP with disappointing results at thispoint.233,234Gibot et als small study evaluatingmedicalpatientswith sepsis of pulmonary (VAP) or extrapulmo-nary origin combined the use of serum procalcitoninand BAL lavage fluid soluble triggering receptor ex-pressed on myeloid cells-1 showed a good correlationwith elevated values and assisted in determination ofpulmonary or extrapulmonary source.235 Procalcitoninmay bemore helpful as a prognosticmarker for whethera patient will have a favorable or unfavorable outcomewhen they have already been diagnosed with VAP,where persistently elevated levels have shown to corre-late with an unfavorable outcome.236,237

Modes of Antimicrobial Delivery. Aerosolizationmay enhance antibiotic delivery to the lower respiratorytract. Agents most studied in this fashion have beenaminoglycosides and polymyxin B. The following stud-ies have been on general ICUpatients and, thus, are notspecific to burns, yet provide some interesting findings.Brown et al238 performed a small prospective random-ized studyof tobramycin vs intravenous therapy inVAP,which failed to show an improvement in clinical out-come, although patients receiving aerosolized tobramy-cin had higher microbiologic eradication rates. Palmer

Table 4. Recommendations for diagnosis of ventilator-associated pneumonia



Clinical findings consistent with pneumonia shouldlead to a quantitative respiratory specimen cultureand a Gram stain

Class II Medical, surgical, trauma,and burns

14, 63, 145148, 151160


et al conducted a more recent double-blind, random-ized, placebo-controlled study of aerosolized vancomy-cin and gentamycin for ventilator-associated tracheo-bronchitis in 43 ICU patients. The aerosolizedantibiotic group had reduced signs of respiratory infec-tion by CDC and CPIS criteria, lower white blood cellcount at day 14, reduced bacterial resistance, reduceduse of systemic antibiotics, and improved ventilatorweaning.239 Claridge et al investigated aerosolizedantibiotics as prophylaxis against VAP in a single-institution, double-blind, randomized trial com-paring a 7-day course of aerosolized ceftazidimewith placebo. In the 105 patients evaluated, theyfound no difference in the incidence of VAP, MDRVAP, or other infectious complications in the twogroups.240 The authors concluded that the prophy-lactic use of aerosolized antibiotics for prophylaxiscannot be recommended.Another mode of antibiotic delivery to be further

investigated is that of continuous vancomycin infu-sion. Several authors have proposed the use of con-tinuous infusion of vancomycin for MRSA VAP. Thisstrategy would involve adjusting the dose of infusionto maintain a serum vancomycin plateau concentra-tion between 20 to 30mg/L.241243 This is attractivebecause vancomycin has poor lung penetration, butthe ability to obtain bacterial killing is concentrationdependent, and intermittent dosing often results insuboptimal serum vancomycin concentrations.Whether continuous infusion of vancomycin leads tosuperior results in the treatment of burn patients withMRSA VAP remains to be investigated.

SUMMARY

VAP is common in mechanically ventilated burn pa-tients, and inhalation injury is a unique risk factor inthis patient population. As such, strategies for preven-

tion, accurate diagnosis, and treatment of VAP areimportant components of the care of the mechani-cally ventilated burn patient. The recommendationsin these guidelines are derived from review of theavailable general critical care and burn literature. Al-though most of the data were obtained by study ofmedical, surgical, and trauma patients and not burnpatients, these important findings are also applicableto the mechanically ventilated, critically ill burn pa-tient (Tables 35). Nevertheless, future studies thatdirectly focus on the critically ill burn populationwould help to validate many of the findings from thecritical care literature and strengthen their applicationin our patients.

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