Treatment of Pediatric Ventilator-Associated Pneumonia (VAP)

Initial Empiric Therapy

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, as recommended by the Infectious Diseases Society of America 1

Consider risk factors for multidrug-resistant organisms (MDROs), including 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, and acute renal replacement therapy prior to VAP onset, as suggested by the Infectious Diseases Society of America 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) are recommended, according to the American Academy of Pediatrics 2, 3
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) 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, as recommended by the Infectious Diseases Society of America 1, 4, 5

For MSSA, cefazolin (150 mg/kg/day every 8 hours) or oxacillin (150-200 mg/kg/day every 6-8 hours) are recommended, according to the American Academy of Pediatrics 4, 5
For MRSA, clindamycin-susceptible, vancomycin (40-60 mg/kg/day every 6-8 hours) or clindamycin (40 mg/kg/day every 6-8 hours) are recommended, as suggested by the Infectious Diseases Society of America 4, 5
For Pseudomonas aeruginosa, cefepime (50 mg/kg/dose every 8 hours) or piperacillin-tazobactam are recommended, according to the Infectious Diseases Society of America 1

Standard duration of therapy is 7-10 days for uncomplicated VAP, as recommended by the Infectious Diseases Society of America 1
Longer treatment courses may be considered for immunocompromised patients or those with inappropriate initial empirical therapy, according to the Journal of Microbiology, Immunology and Infection 8
Modify antibiotic regimen based on microbiological findings to reduce resistance development, as suggested by the European Society of Clinical Microbiology and Infectious Diseases 6, 7

De-escalation of antibiotics should be performed once culture results are available to reduce antibiotic resistance, as recommended by the European Society of Clinical Microbiology and Infectious Diseases 6, 7
For children with comorbidities (immunologic disorders, hematologic, cardiac, or chronic pulmonary conditions), consider broader empiric coverage and consultation with infectious disease specialists, according to the Journal of Microbiology, Immunology and Infection 8