What Are the Optimal Regimens for Adequate Empiric Therapy of Ventilator-Associated Pneumonia and How Can De-Escalation Therapy Be Achieved?

In his valedictory address entitled Aequanimitas, Sir William Osler wrote, ‘‘In seeking absolute truth we aim at the unattainable, and must be content with finding broken portions’’ (1). This philosophical point has applicability in the empiric therapy of ventilator-associated pneumonia (VAP). In attempting to understand the complexities of VAP, the clinician encounters some sobering facts. In their review of VAP, Chastre and Fagon (2) note that mortality rates of ICU patients with this infection ranged from 24% to 76%. The medical literature is replete with reports noting that inadequate therapy for serious infections leads to increased mortality (3-12). Such data can be daunting for the clinician, whose goal of preventing mortality may not be attainable in all patients with VAP. Further complicating the matter is that there does not presently exist a definitive body of medical literature, which has established a gold standard regimen for treating VAP. The absence of such data in the presence of such outcome statistics creates an important broken portion in the practice of critical care medicine.