What is the recommended treatment for pediatric ventilation-associated pneumonia (VAP)?

Treatment of Pediatric Ventilator-Associated Pneumonia (VAP)

For pediatric ventilator-associated pneumonia (VAP), empiric therapy should include a third-generation cephalosporin (ceftriaxone or cefotaxime) plus coverage for methicillin-resistant Staphylococcus aureus (MRSA) with either vancomycin or linezolid if risk factors for MRSA are present, with subsequent de-escalation based on culture results. 1, 2

Initial Assessment and Diagnosis

• VAP is defined as a lung infection occurring after 48 hours of mechanical ventilation requiring a change in ventilator settings (mainly increased oxygen requirement) 2
• Diagnosis is based on clinical presentation, new infiltrate on chest X-ray, and positive culture from a specimen taken preferentially using a sterile sampling technique 2
• Quantitative cultures from bronchoalveolar lavage (≥100,000 CFU/mL) increase the sensitivity and specificity of diagnosis 3, 4

Empiric Antibiotic Selection

Risk Stratification

• Consider risk factors for multidrug-resistant organisms (MDROs) 1:
  • Prior intravenous antibiotic use within 90 days
  • Five or more days of hospitalization prior to VAP
  • Septic shock at time of VAP
  • Acute respiratory distress syndrome preceding VAP
  • Acute renal replacement therapy prior to VAP onset

Recommended Empiric Regimens

1. For early-onset VAP (≤7 days of mechanical ventilation) without MDR risk factors:

   • Ampicillin (150-200 mg/kg/day divided every 6 hours) or penicillin G (200,000-250,000 U/kg/day divided every 4-6 hours) 1
   • Alternative: Ceftriaxone (50-100 mg/kg/day every 12-24 hours) or cefotaxime (150 mg/kg/day every 8 hours) 1

2. For late-onset VAP (>7 days) or presence of MDR risk factors:

   • Antipseudomonal coverage with cefepime (50 mg/kg/dose every 8 hours, maximum 2g) 5, 3
   • PLUS vancomycin (40-60 mg/kg/day divided every 6-8 hours) or linezolid (30 mg/kg/day in 3 doses for children <12 years and 20 mg/kg/day in 2 doses for children ≥12 years) if MRSA is suspected 1

3. For suspected Pseudomonas aeruginosa (particularly in patients with COPD or >1 week of ventilation):

   • Consider double antipseudomonal coverage until culture results are available 1
   • Options include combining cefepime with either an aminoglycoside (amikacin, gentamicin, or tobramycin) or a fluoroquinolone (ciprofloxacin) in older children 1

Pathogen-Specific Therapy (After Culture Results)

Gram-Positive Organisms

• MSSA: Cefazolin (150 mg/kg/day every 8 hours) or oxacillin (150-200 mg/kg/day every 6-8 hours) 1
• MRSA, clindamycin-susceptible: Vancomycin (40-60 mg/kg/day every 6-8 hours) or clindamycin (40 mg/kg/day every 6-8 hours) 1
• MRSA, clindamycin-resistant: Vancomycin or linezolid (30 mg/kg/day in 3 doses for children <12 years) 1
• Group A Streptococcus: Penicillin G (100,000-250,000 U/kg/day every 4-6 hours) or ampicillin (200 mg/kg/day every 6 hours) 1

Gram-Negative Organisms

• Haemophilus influenzae:
  • β-lactamase negative: Ampicillin (150-200 mg/kg/day every 6 hours)
  • β-lactamase positive: Ceftriaxone (50-100 mg/kg/day every 12-24 hours) 1
• Pseudomonas aeruginosa: Cefepime (50 mg/kg/dose every 8 hours) or piperacillin-tazobactam 1, 5
• Stenotrophomonas or Acinetobacter: Consult infectious disease specialist for targeted therapy based on susceptibilities 3

Treatment Duration and Monitoring

• Standard duration of therapy is 7-10 days for uncomplicated VAP 1, 2
• Longer treatment courses may be considered for immunocompromised patients or those with inappropriate initial empirical therapy 1
• Modify antibiotic regimen based on microbiological findings to reduce resistance development 1
• Regular monitoring of local antibiogram patterns is essential to guide empiric therapy, as pathogen distribution and resistance patterns change over time 3

Important Considerations

• De-escalation of antibiotics should be performed once culture results are available to reduce antibiotic resistance 1
• Vancomycin has been associated with poor outcomes in MRSA VAP; consider linezolid as an alternative 1
• Antifungal therapy is not required for Candida colonization in respiratory specimens unless there is evidence of invasive disease 1
• For children with comorbidities (immunologic disorders, hematologic, cardiac, or chronic pulmonary conditions), consider broader empiric coverage and consultation with infectious disease specialists 1