One of the urgent problems of modern intensive care is nosocomial pneumonia, which develops during the period of artificial respiratory support (ventilator-associated pneumonia - VAP) in patients with various variants of conditions criticism.

The risk factors for VAP are the duration of mechanical ventilation (artificial pulmonary ventilation), emergency surgery, the presence of a concomitant pathology, the patient's initial serious state, the position horizontal, the use of muscle relaxants and many others [2].

The pneumonia associated with the ventilator depends on the length of the patient's stay in mechanical ventilation. With the so-called early VAP (development in the first 4 days of mechanical ventilation), the most likely pathogens are S. pneumoniae, H. influenzae, S.aureus (MSSA) and other representatives of the normal microflora of the oral cavity. The development of late VAP (more than 4 days devoted to mechanical ventilation) is associated with P.aeruginosa, Acinetobacter spp., Family representatives Enterobacteriaceae and less often with MRSA [1]. The polymicrobial etiology of VAP is recorded in 40% of cases.

When diagnosed with VAP, a resuscitator experiences greater difficulties than diagnosing hospital pneumonia in spontaneously breathing patients. In order to increase the accuracy of the diagnosis of VAP, a certain number of authors propose a unified integrated approach to the diagnosis of the disease. Experts from the American College of Chest Physicians (ACI) American College of Chest Physicians recommend taking into account signs such as the appearance of changes or focal infiltration in the lungs. combination with at least one of the following:

There is no doubt that it is necessary to use in the diagnosis of PVA with the clinical, laboratory and radiological data of the microbiological approach.

To increase the value of the results of microbiological studies, it is proposed to use the sampling of materials by invasive methods ("protected" brush biopsy, broncho-alveolar lavage - BAL, mini-BAL ), in particular using protected devices. This minimizes contamination of the samples by the microflora of the upper respiratory tract or the endotracheal tube, as well as quantifies the resulting material, differentiating the infectious process from colonization.

With all the objective utility to confirm VAP invasive diagnostic methods, it is worth emphasizing their high cost and the need to attract additional staff. Therefore, in most cases, they remain the methods of scientific research, rather than everyday clinical practice.

Over the past 4 years, the results of several prospective controlled trials have been published which convincingly demonstrate the importance of prescribing adequate empirical antimicrobial therapy for VAP. It turned out that it was only in these circumstances that a decline in mortality was observed. Correcting the therapy after receiving the results of the microbiological studies no longer had the desired effect. For the optimal choice of the ABT empirical scheme, it is necessary to take into account at least five groups of factors simultaneously:

The recommendations given for antibiotic therapy are based on the results of multicenter studies in USA, in which the generalized prevalence of Klebsiella pneumoniae strains, producers of broad spectrum beta-lactamases and the high resistance of non-fermentative Gram negative bacteria with inhibitor resistant antiseptic penicillins are established. Therefore, they should not be used for the empirical treatment of late VAP. The same studies have demonstrated the high activity of amikacin against problematic gram-negative microorganisms - agents responsible for PWA.

At the same time, it should be borne in mind that the benefits of therapy combined with the addition of aminoglycosides are only established in the cases of Pseudomonas aeruginosa, klebsiellosis or the etiology of acinetobacter pneumonia. The constant concentration of these patients in the general service creates the conditions for cross-transmission of bacterial strains, including those with resistance to multiple antibiotics. In these environmental conditions, in addition to implementing certain anti-epidemic measures, a policy of rotation of antibiotics must be pursued to start an empirical therapy. Its feasibility has been proven by a number of researchers.

When choosing antimicrobial drugs (AMP) in a patient with nosocomial pneumonia, the nature of the service in which he is located (general profile or ICU), the use of mechanical ventilation and the time development of the VAP are taken into account. Empirical therapy is planned based on local susceptibility data for likely pathogens. An expectoration test is compulsory, while it is desirable to obtain material by invasive methods with a quantitative evaluation of the results and a blood culture.

The success in improving the results of VAP therapy can be obtained through epidemiological surveillance of hospital infections in the ICU, the use of de-escalation antibiotics, pharmacodynamic approaches for the choice of dosage regimen. Meanwhile, the close relationship of PVA with the severity and underlying course of the underlying disease, as well as the high monetary costs of treatment, prompt the search for effective prevention and the development of reliable methods for predicting from critical conditions.