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Ventilator-Associated Pneumonia — FRCA Final MCQ

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ModerateIntensive Care MedicineVentilator-Associated PneumoniaFRCA Final

A 50-year-old man develops ventilator-associated pneumonia after 7 days of invasive mechanical ventilation. He is haemodynamically stable, has no beta-lactam allergy, has received no antibiotics during this admission and has no history of colonisation with multidrug-resistant organisms. Gram stain of bronchoalveolar lavage fluid shows Gram-negative rods. The local ICU antibiogram supports empirical antipseudomonal beta-lactam monotherapy in such patients, with carbapenems reserved for known resistance or recent broad-spectrum beta-lactam exposure. Which is the most appropriate initial empirical antibiotic pending culture results?

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Correct answer: C — Piperacillin-tazobactam

Piperacillin-tazobactam is the best empirical option. It is an antipseudomonal beta-lactam licensed for VAP and is suitable as monotherapy when the patient is not in septic shock and local susceptibility data support it. The BAL Gram stain also favours Gram-negative coverage. Meropenem would provide appropriate activity but is unnecessarily broad here; carbapenems should generally be reserved for known or strongly suspected resistant organisms, recent relevant antibiotic exposure or failure of narrower treatment. Co-amoxiclav does not reliably cover Pseudomonas and is inadequate for this late VAP scenario. Vancomycin targets Gram-positive organisms, principally when MRSA is suspected, while fluconazole treats susceptible fungal infection rather than bacterial VAP. Therapy must be reviewed promptly against culture and susceptibility results.

Reference: NHS Lothian, Critical Care Antimicrobial Guidance, section 'Bugs and drugs', current webpage accessed August 2026. https://www.rightdecisions.scot.nhs.uk/antimicrobial-prescribing-nhs-lothian/specialty-guidelines/other/critical-care/guidance/