title: From starting mechanical ventilation to ventilator-associated pneumonia, choosing the right moment to start antibiotic treatment.
abstract: BACKGROUND
  Ventilator-associated pneumonia (VAP) can have a clear onset or may be a result of the gradual appearance of symptoms and signs of VAP (gradual VAP). The aim of this paper is to describe the VAP development process with the intention of discriminating between those pneumonias with a clear beginning and those that are diagnosed after a period of maturation. In addition, we evaluate the effect of the starting time of antibiotic treatment in both situations.
  
  
  METHODS
  Consecutive ventilated patients fulfilling VAP criteria were included. The patients were monitored for clinical, microbiological, and inflammatory signs. Patients with VAP were classified into two groups: (1) nongradual VAP (patients in whom all VAP criteria were detected for the first time on the day of diagnosis) and (2) gradual VAP (progressive appearance of signs and symptoms throughout the pre-VAP period [<96 h to >24 h before VAP diagnosis]).
  
  
  RESULTS
  A total of 71 patients with VAP were identified, of whom 43 (61 %) had gradual VAP, most of whom (n = 38, 88 %) had late-onset VAP. Antibiotic treatment was given to 34 (79 %) patients with gradual VAP in the pre-VAP period, and empirical antibiotic treatment was appropriate in 22 patients (51 %). The patients with an appropriate empirical treatment had a higher percentage of early clinical response to treatment (68 % [n = 15] vs. 28 % [n = 7]; p = 0.009). An attempt was made to find a diagnostic test capable of identifying the infectious process underway, but clinical scales and biomarkers of inflammation helped us to achieve acceptable results.
  
  
  CONCLUSIONS
  Gradual emergence of VAP, mainly of late onset, is a common condition. Clinicians should be aware of this gradual onset of the infection to establish an early antibiotic treatment, even before the classic diagnostic criteria for VAP are applied.
authors.affiliation: Department of Intensive Care Medicine, Hospital Universitari i Politècnic la Fe, Valencia, Spain. ramirez_pau@gva.es.|Centro de Investigación Biomedica en Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Instituto de Salud Carlos III, Madrid, Spain. ramirez_pau@gva.es.
authors.forename: Paula
authors.initials: P
authors.lastname: Ramirez
authors.affiliation: Department of Intensive Care Medicine, Hospital Universitari i Politècnic la Fe, Valencia, Spain.
authors.forename: Cristina
authors.initials: C
authors.lastname: Lopez-Ferraz
authors.affiliation: Department of Intensive Care Medicine, Hospital Universitari i Politècnic la Fe, Valencia, Spain.
authors.forename: Monica
authors.initials: M
authors.lastname: Gordon
authors.affiliation: Department of Pneumology, Hospital Universitari i Politècnic la Fe, Valencia, Spain.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Gimeno
authors.affiliation: Department of Intensive Care Medicine, Hospital Universitari i Politècnic la Fe, Valencia, Spain.
authors.forename: Esther
authors.initials: E
authors.lastname: Villarreal
authors.affiliation: Department of Intensive Care Medicine, Hospital Universitari i Politècnic la Fe, Valencia, Spain.
authors.forename: Jesús
authors.initials: J
authors.lastname: Ruiz
authors.affiliation: Centro de Investigación Biomedica en Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Instituto de Salud Carlos III, Madrid, Spain.|Department of Pneumology, Hospital Universitari i Politècnic la Fe, Valencia, Spain.
authors.forename: Rosario
authors.initials: R
authors.lastname: Menendez
authors.affiliation: Centro de Investigación Biomedica en Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Instituto de Salud Carlos III, Madrid, Spain.|Department of Pneumology, Hospital Clinic, Barcelona, Spain.
authors.forename: Antoni
authors.initials: A
authors.lastname: Torres
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000494:pharmacology / Q000627:therapeutic use*; D015415:Biomarkers; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D053717:Pneumonia, Ventilator-Associated / Q000188:drug therapy* / Q000401:mortality; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000009:adverse effects / Q000451:nursing; D013997:Time Factors
chemical_list: D000900:Anti-Bacterial Agents; D015415:Biomarkers
keywords: Appropriate treatment; Inflammatory biomarker; Ventilator-associated pneumonia; Ventilator-associated tracheobronchitis