Abstract
BackgroundThe choice of empirical antimicrobial therapy for pneumonia in intensive care unit (ICU) is a challenge, since pneumonia is often related to multidrug-resistant pathogens, particularly extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E). To prevent the overuse of broad-spectrum antimicrobial therapy, the main objective of this study was to test the performance of digestive colonization surveillance as a predictor of ESBL-E presence or absence in respiratory samples performed in ICU and to evaluate the impact of time sampling (≤5 days or >5 days) on such prediction. Design: Multicentric retrospective observational study, including every patient with a respiratory tract specimen positive culture and a previous rectal ESBL-E screening performed within 7 days before the respiratory sample, between January 2012 and December 2014. Results were analyzed in two groups: respiratory samples obtained during the first 5 days of ICU stay (early group) and respiratory samples obtained after 5 days (late group). Interventions: none.ResultsAmong 2498 respiratory tract samples analyzed corresponding to 1503 patients, 1557 (62.3%) were performed early (≤5 days) and 941 (37.7%) later (>5 days). Positivity rates for ESBL-E were 15.0 and 36.8% for rectal swabs in the early and late groups, respectively. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and likelihood ratios were calculated for ESBL-E digestive colonization as a predictor of ESBL-E presence in respiratory samples. PPVs of ESBL-E digestive colonization were 14.5% (95% CI [12.8; 16.3]) and 34.4% (95% CI [31.4; 37.4]), for the early and late groups, respectively, whereas NPVs were 99.2% (95% CI [98.7; 99.6]) and 93.4% (95% CI [91.9; 95.0]), respectively.ConclusionsSystematic surveillance of ESBL-E digestive colonization may be useful to limit the use of carbapenems when pneumonia is suspected in ICU. When rectal swabs are negative, the risk of having ESBL-E in respiratory samples is very low even after 5 days of ICU stay.
Highlights
The choice of empirical antimicrobial therapy for pneumonia in intensive care unit (ICU) is a challenge, since pneumonia is often related to multidrug-resistant pathogens, extended-spectrum β-lactamaseproducing Enterobacteriaceae (ESBL-E)
We have previously shown that microbiological examination of upper airways samples at ICU admission predicts the microorganisms involved in ventilator-associated pneumonia (VAP) occurring in the early course of a patient’s ICU stay with a high specificity and likelihood ratio [22]
Relying on our results and on the American thoracic society guidelines [11], we suggest a decision tree for empirical antimicrobial therapy in patients with respiratory tract specimen positive culture and suspicion of pneumonia (Fig. 3)
Summary
The choice of empirical antimicrobial therapy for pneumonia in intensive care unit (ICU) is a challenge, since pneumonia is often related to multidrug-resistant pathogens, extended-spectrum β-lactamaseproducing Enterobacteriaceae (ESBL-E). Community-acquired, hospital-acquired and ventilator-associated pneumonia (VAP) are the most common infections in intensive care units (ICU). They are associated with high morbidity and mortality rates [1, 2], if the administration of appropriate antimicrobial therapy is delayed [3,4,5,6]. Because of frequent long hospital stays, complex underlying pathologies and previous antimicrobial exposure, pneumonia is often related to multidrug-resistant (MDR) pathogens, extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) [8, 9]. The use of local epidemiological data and individual patient risk factors leads to frequent empirical prescription of broad-spectrum antimicrobial therapy, including carbapenems [11,12,13], leading to the emergence of MDR pathogens [14], especially carbapenemase-producing Enterobacteriaceae [15]
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