Authors: Lamamri M et al.
Anaesthesia Critical Care & Pain Medicine, 2025, Article 101726
This international survey study (OPTI-VAP) explored how ICU clinicians decide when to start antibiotics in cases of suspected non-severe ventilator-associated pneumonia (VAP). While current guidelines generally support immediate empiric antibiotic therapy, this approach raises concerns about antimicrobial overuse and resistance. The study aimed to understand real-world practice patterns and what factors influence decision-making.
A total of 163 physicians from 142 centers across 27 countries responded, with the majority practicing in France and India. Despite the “non-severe” designation, most clinicians (62.6%) reported that they routinely initiate immediate empiric antibiotics when VAP is suspected.
The study identified key drivers behind this decision. Clinicians were more likely to start antibiotics immediately if bronchoalveolar lavage (BAL) was performed, suggesting that invasive diagnostic evaluation often coincides with a more aggressive treatment approach. In contrast, access to rapid diagnostic tools—particularly Gram stain results—was associated with a greater likelihood of delaying antibiotics, presumably because clinicians felt more comfortable waiting for early microbiologic data.
The main clinical triggers for immediate antibiotic initiation were worsening oxygenation and new or progressive pulmonary infiltrates on imaging. These findings highlight that even in “non-severe” VAP, clinicians tend to prioritize early treatment when there are signs of physiologic deterioration.
Importantly, the study reveals substantial variability in practice across institutions and countries. This variability appears to be driven less by differences in clinical philosophy and more by differences in available diagnostic resources and workflow efficiency. Where rapid diagnostics are available, clinicians are more willing to delay antibiotics; where they are not, empiric therapy is started early.
As a survey-based study, these findings reflect clinician behavior rather than patient outcomes. However, they underscore a key tension in modern ICU care: balancing the risks of delayed therapy against the long-term consequences of antibiotic overuse. The authors emphasize the need for randomized trials to determine whether delayed strategies are safe in selected non-severe VAP patients.
Key Points
- Most ICU clinicians (62.6%) initiate immediate empiric antibiotics for suspected non-severe VAP
- Worsening oxygenation and imaging findings are the main drivers of early treatment
- Use of bronchoalveolar lavage is associated with immediate antibiotic initiation
- Availability of rapid diagnostics (e.g., Gram stain) supports delayed antibiotic strategies
- Significant global variability exists, largely based on resource availability and workflow
What You Should Know
This study highlights a real-world disconnect between antimicrobial stewardship goals and bedside decision-making. Even in non-severe VAP, most clinicians are not comfortable delaying antibiotics—especially when patients show early signs of deterioration. If your ICU has rapid diagnostic capabilities, you may have more flexibility to delay therapy safely. Without them, early empiric treatment remains the default. The takeaway is simple: improving diagnostic speed and reliability may be the only realistic way to safely reduce unnecessary antibiotic use in VAP.
We want to thank Anaesthesia Critical Care & Pain Medicine for allowing us to summarize and share this important work with the anesthesia community.