SP27-3 Treatment of noscomial pneumonia

Abstract

SP27-2 Treatment for healthcare associated pneumonia W.-H. Sheng*. National Taiwan University Hospital, Taiwan Hospital acquired pneumonia (HAP) is one of the leading cause of healthcare associated infections in intensive care units (ICU). Ventilator-associated pneumonia (VAP) is the most common type of HAP. Patients who acquire HAP/VAP have higher mortality rates and longer ICU and hospital stays. HAP/VAP also is characterized with severe underlying systemic diseases and causative pathogens of multi-drug resistance, such as methicillin-resistant Staphylococcus aureus , Pseudomonas aeruginosa and carbapenem-resistant Enterobacteriaceae. Delayed administration of adequate antibiotic therapy is linked to an increased mortality rate. Therefore, the initial antibiotic therapy should be to rapidly provide coverage for all likely pathogens and to then narrow the antibiotic spectrum based on the results of quantitative cultures by bronchoscopic examination. The optimal antibiotic strategy for the treatment of HAP remains controversial. According to the ATS/IDSA guideline, initial treatment for mild– moderate HAP without risk for multidrug resistant microorganisms (MDRO), a fluoroquinolone (levofloxacin or moxifloxacin), or amoxicillin/clavulanate plus a macrolide has been suggested. For patients with severe HAP/VAP, late onset of VAP, with risk for MDRO, an antipseudomonal cephalosporin (cefepime, ceftazidime), or an antipseudomonal carbapenem (imipenem, meropenem), or a b-lactam/b-lactamase inhibitor (piperacillin/tazobactam) plus an antipseudomonal fluoroquinolone (levofloxacin, ciprofloxacin), or an aminoglycoside (amikacin, gentamicin, tobramycin) plus either linezolid or vancomycin is suggested. Clinical improvement usually takes 48 to 72h, therefore, unless the patient is declining clinically, antibiotics should not be modified during this time unless dictated by the results of microbiologic sensitivity. Eight days of antibiotic therapy appears equivalent to 15 daysof therapy except when treating non-glucose fermenting Gram-negative bacteria. A guideline-based approach using the local hospital or ICU antibiogram can increase the likelihood that adequate initial antibiotic therapy is used and reduce the overall use of antibiotics and the associated selection pressure for MDRO. In conclusion, a systematically applied strategy that addresses early intervention with broad-spectrum antibiotics based on the risks for MDRO, and which is appropriate to the local antibiogram, can improve outcomes. This strategy also includes quantitative culture of respiratory secretions, de-escalation of antibiotic therapy once culture results are available, and discontinuation of antibiotics after 8 daysof treatment in patients without Pseudomonas or Acinetobacter as the causative pathogens.