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Article infectious diseases

Ventilator-Associated Pneumonia in
Neonates: An Update
Jeffery S. Garland, MD, Practice Gaps
1. Accurately determining the specific organism responsible for ventilator-associated
pneumonia is challenging in neonates.
Author Disclosure 2. Few randomized trials have been conducted to evaluate measures to prevent
Dr Garland has ventilator-associated pneumonia in neonates.
disclosed no financial 3. It is not known whether a level or head-elevated position influences the risk of
relationships relevant ventilator-associated pneumonia (VAP).
to this article. This
commentary does not Abstract
contain a discussion of Health-careassociated infections affect neonatal morbidity and mortality, as well as
length of stay and hospital costs. Ventilator-associated pneumonia (VAP) accounts
an unapproved/
for 6.8% to 32.2% of these infections. Low birthweight, duration of mechanical ven-
investigative use of
tilation, opiate treatment for sedation, frequent suctioning, and reintubation have all
a commercial product/ been shown to increase the risk of VAP. Both Gram-positive and Gram-negative or-
device. ganisms that originate from endogenous or exogenous sources are responsible for
VAP. Accurately diagnosing VAP in neonates is challenging because procedures such
as tracheal aspirate culture and Gram-stain have low sensitivity, specicity, and positive
predictive value. Although several authors have shown that bronchial aspirates through
nonbronchoscopic bronchoalveolar lavage improve diagnostic accuracy, further stud-
ies are needed to investigate the diagnostic value and safety prole of these procedures.
Very few randomized trials have been conducted in neonates to evaluate methods to
prevent VAP, and thus most neonatal VAP prevention recommendations are based on
adult trials. This review summarizes the epidemiology, pathogenesis, diagnosis, and
treatment of VAP and touches on a number of practical steps to prevent VAP in

Objectives After completing this article, the reader should be able to:
1. Describe the risk factors for neonatal ventilator-associated pneumonia (VAP).
2. Describe the current methods used to diagnose neonatal VAP.
3. List the most common organisms responsible for neonatal VAP.
4. Explain initial treatment of neonatal VAP.
5. Outline steps to prevent neonatal VAP.

The Centers for Disease Control and Prevention (CDC) denes ventilator-associated
pneumonia (VAP) as an episode of pneumonia in a patient
who requires a device to assist or control respiration through
a tracheostomy or endotracheal tube within 48 hours before
Abbreviations the onset of the infection. (1) Although the exact incidence
CDC: Centers for Disease Control and Prevention of VAP is difcult to determine, VAP may be responsible for
NHSN: National Healthcare Safety Network as many as one-third of the health-carerelated infections in
SDD: selective digestive tract decontamination neonates. (2)(3)(4)(5)(6) The present review summarizes
VAP: ventilator-associated pneumonia the epidemiology, suspected pathogenesis, diagnosis, treat-
ment, and strategies for the prevention of VAP in neonates.

*Director of Neonatal-Perinatal Research, Wheaton Franciscan HealthcareSt Joseph Hospital, Milwaukee, WI.

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Epidemiology exogenous sources (Figs 1 and 2). A number of inves-

Increased permeability of the skin and mucous mem- tigators have described the role of pharyngeal and
branes, decreased complement activity, lower concen- subglottic secretions in the development of VAP in
trations of immunoglobulins, and an immature and adults. (16)(17)(18)(19)(20) Contaminated oral or
dysregulated immune system together increase the risk gastric secretions of intubated, ventilated adult patients
of health-careacquired infections in critically ill neo- can pool above the cuff of the endotracheal tube, leak
nates. Multiple physiologic mechanisms optimally protect around the cuff, and enter the lower respiratory tract. Be-
the lung parenchyma from infection, including: anatom- cause neonates are ventilated with uncuffed endotracheal
ical barriers; the cough reex; the tracheobronchial mu- tubes, they are likely at greater risk for aspiration of con-
cociliary lining and secretions; and cell-mediated and taminated oral or gastric secretions. Within the rst 48
humoral immunity, including the phagocytic functions hours of mechanical ventilation, (21)(22) Gram-positive
of alveolar macrophages and neutrophils. If these de- oral organisms begin to colonize the trachea and endotra-
fenses are impaired, absent, or overcome by a high cheal tube, and Gram-negative bacilli generally colonize
inoculum of organisms or those of unusual virulence, endotracheal tubes in place for longer than 48 hours.
pneumonitis ensues. One study provided some evidence that neonatal position-
Data from the CDCs National Healthcare Safety Net- ing may inuence the incidence of lower respiratory tract
work (NHSN) (20062008) at 304 participating hospi- bacterial colonization. (23) In this study, tracheal coloni-
tals revealed VAP rates of 2.36 and 2.08 per 1,000 zation was less common among neonates placed in a lateral
device-days among neonates weighing less than 750 g position compared with neonates nursed in a supine
and between 750 and 1,000 g, respectively. (7) The true position.
rate of neonatal VAP is difcult to establish. Radiographic Organisms responsible for VAP may also originate
identication of neonatal pneumonia is difcult, compro- from the stomach, although the exact role gastric ora
mised by evolving parenchymal changes due to broncho- plays in the pathogenesis of VAP has been questioned.
pulmonary dysplasia and frequent episodes of atelectasis. (24)(25) Torres et al (26) noted that VAP in adults
Diagnostic procedures commonly used in adults to diag- was more common among supine patients compared
nose VAP (eg, bronchoscopic bronchoalveolar lavage, with semi-recumbent patients. Farhath et al (27) noted
protected specimen brushing) are
rarely used in the neonatal intensive
care unit (NICU), in part due to the
small size of neonatal endotracheal
tubes. Retrospective cohort studies
conducted at single institutions re-
port higher VAP rates (10.952 in-
fections per 1,000 ventilator-days)
than NHSN data. (2)(8)(9)(10)
(11)(12)(13) Risk factors reported
to be signicantly associated with
VAP among ventilated neonates
also vary from study to study. Low
birthweight, prolonged mechanical
ventilation, opiate treatment for se-
dation, frequent suctioning and re-
intubation, bloodstream infection,
and steroid use have all been noted
to be associated with increased risk
of VAP. (14)(15)

Pathogenesis Figure 1. Endogenous sources of organisms responsible for ventilator-associated

Organisms responsible for VAP pneumonia (VAP). (Courtesy of Walt Earhart, Wheaton Franciscan Healthcare. From:
can originate from endogenous or NeoreviewsPlus August 2010, Question 8, by AAP.)

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that can lead to VAP. Gram-negative

organisms, which often colonize en-
dotracheal tubes, are frequently
noted in the ora that colonize the
hands of caregivers. (30)(31)

In adult and pediatric patients in
whom reliable cultures can be ob-
tained, Staphylococcus aureus and
Gram-negative organisms (Pseudomonas
aeruginosa, Escherichia coli, Klebsiella
pneumoniae, Enterobacter species, and
Acinetobacter species) are the most
common pathogens responsible for
VAP. Gram-negative organisms were
noted in 94% of tracheal aspirates
from neonates who had VAP in a co-
hort reported by Apisarnthanarak
et al. (13) S aureus was recovered
from w25% of cases, and multiple
Figure 2. Exogenous sources of organisms responsible for ventilator-associated organisms were recovered from air-
pneumonia (VAP). (Courtesy of Walt Earhart, Wheaton Franciscan Healthcare. From: way secretions in 58% of cases. In a re-
NeoreviewsPlus August 2010, Question 8, by AAP.) cent work by Cernada et al, (32)
gram-negative organisms (particu-
that pepsin, a marker for gastric contents, was detected in larly P aeruginosa) were responsible for 62% of VAP
the trachea of 92% of a cohort of ventilated neonates, sug- cases. This study diagnosed VAP by using bronchoalveolar
gesting that contaminated gastric contents could make lavage with a blind protected catheter; with this tech-
their way into the trachea of ventilated neonates. Based nique, only 3 (16.7%) of 18 neonates had polymicrobial
on trials that used rigorous culturing techniques and stan- infections.
dard denitions of VAP, oropharyngeal colonization likely
plays a greater role than aspiration of contaminated gastric
The primary controversy regarding VAP in neonates is
secretions. (22) Although previous bloodstream infection
the criteria used to establish the diagnosis. (33) The
has been identied as a risk factor for VAP, these infections
CDCs NHSN VAP criteria included radiographic, clin-
do not seem to be the source of VAP. (13) Bloodstream
ical, and microbiologic elements. (1) The difculty in ob-
infections and translocation of bacteria from the gastroin-
taining noncontaminated microbiologic specimens that
testinal tract are also believed to be an uncommon source meet quantitative denitions for infection led the CDC
of endogenous organisms responsible for VAP. to include a purely clinical denition of VAP for infants
Exogenous sources may also be responsible for the aged 1 year, as shown in Table 1. The criteria have
pathogens causing VAP (Fig 2). Shortly after intubation, not been validated in neonates, and they are often open
bacteria can coat the surface of endotracheal tubes and to subjective interpretation because they overlap with
become enveloped within a biolm produced by the mi- a number of disease processes. As of January 1, 2014,
crobes. This biolm can serve as an exogenous source of the CDC and NHSN no longer analyze data for neonatal
organisms responsible for VAP. In a study of adult pa- pneumonia because the diagnosis is so subjective accord-
tients, Adair et al (28) noted that 70% of patients who ing to a CDC working group. (34) Neonatal units may
have VAP had the same pathogens isolated from endotra- still perform internal VAP surveillance, but the data will
cheal biolms and tracheal secretions. Pathogens that not be analyzed by the NHSN.
contaminate ventilator circuits, airway suctioning equip- Microbiologic criteria for VAP are shown in Table 2.
ment, humidiers, nebulizers, and, most importantly, care- (1) Note that these criteria presume that pulmonary
givers hands (29) are sources of exogenous contamination specimens are obtained by using invasive testing, such

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CDC Alternate Criteria for Diagnosis of VAP Among Infants Age

Table 1.

1 Year
Radiographic criteriaa
New or progressive infiltrate and persistent infiltrate
Clinical criteria
Worsening gas exchange (eg, oxygen desaturations, increased oxygen requirements, increased ventilator demand)
And three of the following
Temperature instability
Leukopenia (<4,000 WBC/mm3) or leukocytosis (>15,000 WBC/mm3) and left shift (>10% band forms)
New onset of purulent sputum or change in character of sputum, or increased respiratory secretions or increased suctioning
Apnea, tachypnea, nasal flaring with retraction of chest wall or nasal flaring with grunting
Wheezing, rales, or rhonchi
Bradycardia (<100 beats per minute) or tachycardia (>170 beats per minute)
CDCCenters for Disease Control and Prevention; VAPventilator-assisted pneumonia; WBCwhite blood cell count.
In the absence of underlying conditions, one denitive chest radiograph is acceptable. Among infants who have underlying conditions, two or more serial
denitive radiographs are required. For neonates, underlying pulmonary or cardiac disease may include respiratory distress syndrome, bronchopulmonary
dysplasia, pulmonary edema, chronic obstructive pulmonary disease, and/or congenital heart disease.

as those obtained with bronchoalveolar lavage or through VAP had positive lavage culture results. Sensitivity, spec-
a protected specimen brush, frequently used to diagnose icity, and positive and negative predictive values were
VAP in adults. As mentioned earlier, both techniques 90%, 90%, 70%, and 97%, respectively. The presence of
need to be performed through a bronchoscope, thus pre- intracellular bacteria in polymorphonuclear cells on
cluding their widespread use in intubated neonates. Giemsa-stained smears was signicantly higher in neo-
Kksal et al (35) used invasive testing with nonbroncho- nates who have VAP compared with colonized neonates.
scopic bronchoalveolar lavage to obtain specimens from There were no signicant complications, but because the
ventilated neonates with suspected pneumonia. Ninety procedure is blind to what actually is being cultured, it is
percent of the 40 neonates who had clinically diagnosed possible that the samples were taken more proximally

CDC Microbiologic Criteria for Diagnosis of Common Bacterial or

Table 2.

Fungal VAP
In addition to radiographic and clinical criteria, at least one of the following is present:
Positive growth in blood culture not related to another source of infection
Positive growth in culture of pleural fluid
Positive quantitative culture from minimally contaminated lower respiratory tract specimen (eg, BAL, protected specimen
5% BAL-obtained cells contain intracellular bacteria on direct microscopic examination (eg, Gram-stain)
Histopathologic examination shows at least one of the following indications of pneumonia:
- Abscess formation or foci of consolidation with intense PMN accumulation in bronchioles and alveoli
- Positive quantitative culture of lung parenchyma
- Evidence of lung parenchyma invasion by fungal hyphae or pseudohyphae
BALbronchoalveolar lavage; CDCCenters for Disease Control and Prevention; PMNpolymorphonuclear leukocyte; VAPventilator-assisted

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from the trachea. Cernada et al (32) used a blind pro- initial empiric therapy if local ora include extensive beta-
tected catheter to assist in diagnosing pneumonia in an- lactamaseproducing organisms. Additional Gram-negative
other cohort of neonates who had suspected VAP. They coverage with an aminoglycoside is controversial but may
did not report sensitivity or specicity of the procedure. A be indicated when bacteremia is suspected or signicant
limitation of both of these studies is that they were com- systemic symptoms are present. If systemic symptoms
pared with clinically diagnosed VAP and not with a gold are absent and the blood culture result is negative, de-
standard such as a lung biopsy or tissue sample. Larger escalating therapy by discontinuing the aminoglycosides
trials need to be conducted to assess the diagnostic value may be appropriate. Gram-positive coverage for methicillin-
and safety prole of the procedures. resistant S aureus may be required if local epidemiologic
In many NICUs, tracheal aspirate cultures and Gram- data dictate its use.
stains are commonly used to try to establish the diagnosis Overall, multiple risk factors (eg, prolonged me-
of VAP in neonates. Tracheal aspirates have low sensitiv- chanical ventilation, previous antibiotic exposure, mul-
ity, specicity, and positive predictive value for diagnos- tisystem illness) place neonates at increased risk for
ing VAP because it is difcult to distinguish between multidrug-resistant VAP, and there is no validated
tracheal colonization and true pneumonia. (36) However, means of assessing VAP severity or VAP improvement
tracheal colonization of the airway with Gram-negative after treatment, as there is in adults. Because of these
bacteria has been associated with adverse outcomes. factors, most neonates who have VAP will receive a full
(37) Tracheal aspirates from neonates who have sus- course of empiric broad-spectrum antibiotic therapy
pected VAP may play a role in helping to identify or- unless specic culture results allow for the use of more
ganisms colonizing the airway and aid in the choice narrow-spectrum therapy. (14)(15)
of appropriate antibiotic therapy. This nding may
be of value, given evidence that there is a greater risk of
death in adults from VAP if their pneumonia was initially Prevention of VAP
treated with the wrong antibiotic. (38)(39) Furthermore, The CDC (42) and the American Thoracic Society (43)
a sterile tracheal aspirate culture may also be of value in have published guidelines for the prevention of health-
that sterile cultures have a high negative predictive value careassociated pneumonia. Bundles bring together
for VAP. (40) a number of evidence-based practices that, when applied
Routine use of clinical biomarkers such as C-reactive as a single intervention (ie, the bundle), may result in im-
protein, soluble triggering receptor expressed on mye- provement that is greater than single evidence-based
loid type 1 cells, or procalcitonin to help identify VAP practices. (44)(45)(46) These recommendations address
has not been supported in ventilated adults. (41) Stud- the following specic items.
ies have not been conducted to determine the utility
of biomarkers for the diagnosis of VAP in neonatal Management of secretions and techniques for
patients. suctioning
Adult VAP prevention bundles often include 30 to 45
of head elevation to prevent aspiration of contaminated
Treatment oropharyngeal and gastric uids. The results of Aly
There are no clear consensus guidelines for the optimal et al (23) and Farhath et al (27) suggest that gravity
treatment of neonatal VAP. Most treatment recommen- may be used to prevent pathogens from gaining entry in-
dations are taken from adult guidelines and are supported to the lower respiratory track of ventilated neonates.
by epidemiologic principles. Initial treatment should in- Farhath et al showed that a majority of ventilated neo-
clude broad empiric therapy, preferably informed by local nates aspirated gastric pepsin, perhaps providing support
bacterial colonizing and antimicrobial sensitivity data. for elevating the head of the neonatal bed, but this study
Local NICU antibiotic combinations for the empiric did not evaluate the association between the presence
treatment of late-onset bloodstream infections should of pepsin in the trachea and VAP. Aly et al evaluated
be used for suspected VAP, unless individual infant tracheal colonization in supine and lateral-nursed venti-
colonizing information is available. Empiric treatment lated infants and found that the lateral-nursed infants
will often include an antipseudomonal agent such as had less tracheal bacterial colonization; however, the
piperacillin/tazobactam or ticarcillin/clavulanate to pro- study did not specically assess VAP. The optimum po-
vide coverage of both Gram-negative and Gram-positive sition to nurse neonates for the prevention of VAP needs
organisms. Carbapenems may be more appropriate for further investigation.

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The CDC recommends that secretions be cleared VAP in adults, current data do not support such treat-
from above the cuff of the endotracheal tube anytime ment in ventilated neonates. In addition, the use of
the tube is repositioned or removed. (42) Neonates are H2-blockers is associated with increased risk of late-onset
usually cared for with uncuffed endotracheal tubes. Suc- fungal infection and necrotizing enterocolitis among very
tioning the oropharynx around the endotracheal tube be- low birthweight NICU infants. (51)(52)
fore adjusting it or removing it may reduce risk of Selective digestive tract decontamination (SDD) with
microaspiration of contaminated oropharyngeal secre- enteral nonabsorbable antimicrobials and antimicrobials
tions. Although close systems are frequently used for applied directly to the oropharynx can decrease gastroin-
the care of ventilated neonates, they may present the po- testinal colonization and potentially reduce respiratory
tential for bacterial contamination if pooled secretions in tract infections from microaspiration of gastrointestinal
the lumen are reintroduced into the respiratory tract with organisms. CDC guidelines (42) offer no recommenda-
repeated suctioning. Conversely, closed suctioning could tion for the selective decontamination of the digestive
potentially reduce environmental contamination of the tract. In a nonrandomized prospective trial of ventilated
respiratory tract. In a study of 133 ventilated neonates neonates, those who underwent SDD with polymyxin E,
randomized to a closed or open suction system, no differ- tobramycin, and nystatin had fewer nosocomial infections
ence was noted in tracheal colonization patterns between of intestinal origin. (53) VAP episodes were not reported
groups, nor were there differences in VAP rates among separately. SDD should be evaluated further before it is
treatment groups. Physiologic disruptions were less with considered for neonates outside of clinical trials. The
the closed suction systems, and NICU nurses indicated use of probiotic treatment to inuence neonatal gastroin-
that these systems were easier to use than open suction testinal colonization has focused on reducing late-onset
systems. (47) At minimum, separate suctioning equip- bloodstream infections and necrotizing enterocolitis,
ment should be used for tracheal and oral secretions. but one recent trial of Lactobacillus reuteri administration
One recent study evaluated a low-sodium, physiolog- also demonstrated the effect of probiotic administration
ically based solution for suctioning of ventilated neo- on the incidence of VAP. (54)
nates. (48) A signicant reduction in the VAP rate was The CDC recommends a comprehensive oral hygiene
demonstrated after normal saline for airway suctioning program in patients at high risk for health-careassociated
was replaced by the novel solution for airway suctioning. pneumonia. (42) Although several groups have noted
Further trials with the solutions are necessary to conrm a reduction in VAP among adult patients treated with
these results. Finally, respiratory tubing should be oral chlorhexidine gluconate decontamination, the
drained away from ventilated infants to prevent aspiration CDC makes no recommendation for the use of an oral
of potentially contaminated condensate. (49) Breathing chlorhexidine gluconate rinse for the prevention of
circuits do not need routine changing unless they become VAP in ill patients. Chlorhexidine gluconate is not ap-
visibly soiled or they malfunction. (42) proved for neonates less than age 2 months. Because neo-
nates do not have gingivitis or the dental diseases adults
Extubation procedures often have, oral care may not provide the benet it does
VAP reduction bundles often recommend sedation va- in adult patients. Until further data are available, adhering
cations to assess extubation readiness. Because many to the recommendation of the American Dental Associ-
centers use minimal or no sedation for ventilated neo- ation to wipe off the gums and keep the mouth clean after
nates, sedation vacations are uncommon in most units. feedings and when needed seems prudent.
Assessing for extubation readiness should be done on
a daily basis. Noninvasive measures such as nasal contin-
uous positive airway pressure and nasal prong ventilation Infection control measures
may help to reduce VAP rates. (9) Reintubation after ex- Hand hygiene is likely the most important infection con-
tubation should be avoided if possible because of the in- trol intervention in health-care settings to reduce person
creased risk of VAP associated with reintubation. (50) person transmission of bacteria. Pathogens responsible
for neonatal VAP are carried on health-care workers
Gastrointestinal and oropharyngeal hands and in the infants gastrointestinal tracts. Respira-
interventions. tory equipment can become colonized with these organ-
Manipulation of gastrointestinal contents is part of adult isms. (55) Thorough hand-washing before and after
VAP prevention. Although H2-blocker treatment is fre- contact with respiratory equipment should reduce
quently a standard intervention in bundles to prevent cross-contamination between patients.

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Figure 3. Relationship between preventative measures and pathogenesis of ventilator-associated pneumonia (VAP). (Adapted from
Garland JS. Strategies to prevent ventilator-associated pneumonia in neonates. Clin Perinatol. 2010;37(3):638. Copyright 2010,
with permission from Elsevier.)

Changes in endotracheal tube design have decreased tablished before the effectiveness of these strategies can
incidence of VAP in adults. A hole in the dorsal aspect be accurately assessed.
of endotracheal tubes above the inated cuff allows for
clearing of subglottic secretions. The CDC recommends
the use of such tubes in ventilated adults. (42) Unfortu- American Board of Pediatrics NeonatalPerinatal
nately, such tubes are not available for neonates. Silver- Content Specifications
coated endotracheal tubes, which are not available for Know the pathogenesis and causative
neonates, have also been shown to reduce VAP in adults agents in an infant in whom neonatal
by reducing biolm formation and bacterial colonization. pneumonia is suspected.
Plan the clinical, imaging, and laboratory
Figure 3 summarizes how practical preventative inter-
features and the management of an
ventions relate to the steps in the pathogenesis of VAP. infant in whom neonatal pneumonia is
Improved diagnostic criteria and surveillance tech- suspected.
niques for VAP in the neonatal population need to be es-

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1. A 10-day-old, 28-week-gestational-age male infant who has been on the ventilator has worsening clinical
status and is suspected of having pneumonia. Which of the following statements regarding the development of
ventilator-associated pneumonia (VAP) is correct?
A. Radiographic characteristics of VAP are very distinct and consistent, with a diffuse pattern of consolidation
at onset.
B. A patient needs to be intubated for at least 5 days before onset of infection to have an official diagnosis of
C. Opiate treatment for sedation has been associated with increased risk of VAP.
D. A key feature in effective prevention of VAP is frequent suctioning and periodic replacement of the
endotracheal tube.
E. A concurrent bloodstream infection rules out the diagnosis of VAP.

2. In the 10-day-old, 28-week-gestational-age patient, which of the following statements regarding diagnosis
of VAP is correct?
A. It would be considered the standard of care to perform bronchoscopic bronchoalveolar lavage for the
purpose of diagnosis in this patient.
B. The definition of VAP for neonates has been well established since the 1998 criteria published in a joint
effort between the Centers for Disease Control and Prevention and the American Academy of Pediatrics.
C. A sterile tracheal aspirate culture has a high negative predictive value for VAP.
D. Tracheal aspirates have excellent sensitivity (>98%) but poor specificity for diagnosis of VAP.
E. C-reactive protein has been very useful in the diagnosis of VAP, for distinguishing VAP from other disease
processes, and for use in trials for establishing diagnostic criteria.

3. A tracheal aspirate is obtained from the patient who is suspected of having VAP. Which of the following has
been found regarding tracheal aspirates in neonates who have VAP?
A. Gram-positive organisms are the most common bacteria noted in tracheal aspirates.
B. In general, the most common finding from tracheal aspirates of neonates suspected of having VAP are
sterile or have a single-organism growth.
C. Streptococcus gallolyticus is found in 50% of neonates who have VAP.
D. Bronchoalveolar lavage with a blind protected catheter generally results in higher recovery of
polymicrobial infections.
E. Pseudomonas aeruginosa is a pathogen recovered from airway secretions in VAP by using both tracheal
aspirate and bronchoalveolar lavage methods.

4. The clinical care team has determined that the patient has VAP. What are appropriate principles regarding
treatment for VAP in neonates at this gestational age?
A. Clear consensus guidelines for the treatment of very low birthweight infants were published by the Centers
for Disease Control and Prevention (CDC), first in 1999 and updated in 2010.
B. In the majority of cases, if the patients condition is stable, the treatment of VAP is extubation to
continuous positive airway pressure or nasal cannula, and does not require antibiotics.
C. Antibiotics should only be started after a pathogenic organism associated with VAP has been identified.
D. Empiric treatment may include an antipseudomonal agent such as piperacillin/tazobactam.
E. Because organisms causing VAP are generally derived from mouth flora, penicillin is a reasonable first-line
treatment or can be used if treatment is desired when no organism is recovered.

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5. Your neonatal intensive care unit (NICU) is developing a bundle for prevention of VAP. Which of the following
components may be a reasonable part of the protocol based on the studies discussed in this article?
A. Neonate should be positioned in the prone position at least one-half of the time if he or she has been
intubated for more than 2 days.
B. Separate suctioning equipment should be used for tracheal and oral secretions.
C. Respiratory circuits should be changed on a routine basis, daily or twice a day.
D. Normal saline has been shown to be the optimal solution for airway suctioning compared with all other
E. To minimize gastric aspiration, moderate sedation for vigorously moving infants should be applied,
preferably with opioids.

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Ventilator-Associated Pneumonia in Neonates: An Update
Jeffery S. Garland
NeoReviews 2014;15;e225
DOI: 10.1542/neo.15-6-e225

Updated Information & including high resolution figures, can be found at:
References This article cites 53 articles, 11 of which you can access for free at:
Subspecialty Collections This article, along with others on similar topics, appears in the
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Ventilator-Associated Pneumonia in Neonates: An Update
Jeffery S. Garland
NeoReviews 2014;15;e225
DOI: 10.1542/neo.15-6-e225

The online version of this article, along with updated information and services, is
located on the World Wide Web at:

Neoreviews is the official journal of the American Academy of Pediatrics. A monthly publication,
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