Ventilator-associated pneumonia: monotherapy is optimal if chosen wisely

Burke A Cunha

doi:10.1186/cc4908

Abstract

Traditionally, ventilator-associated pneumonia (VAP) has been treated either with double drug therapy or with monotherapy. Double drug therapy has been used to increase spectrum, for possible synergy, and to decrease the emergence of resistance. VAP therapy should be directed primarily against Pseudomonas aeruginosa, which also provides aerobic Gram-negative coverage, the usual pathogens in VAP. The potent anti-P. aeruginosa antibiotics available today have sufficient activity that double drug coverage is unnecessary. Double drug therapy does not decrease resistance if a 'high resistance potential' antibiotic is used in the combination. The study by Damas and colleagues in this issue of Critical Care supports monotherapy for VAP. Optimal therapy for VAP involves selecting a potent anti-P. aeruginosa antibiotic with a 'low resistance potential' that minimizes drug-drug interactions, minimizes resistance, and is cost effective. Monotherapy of VAP should be the standard of care.

Highlights

Empiric antimicrobial therapy of ventilator-associated pneumonia (VAP) should possess a high degree of activity against aerobic Gram-negative bacilli (GNB)
Antibiotics with a high degree of P. aeruginosa activity are effective against other aerobic GNB causing VAP, that is, Escherichia coli, Klebsiella pneumoniae and Serratia marcescens
In VAP, respiratory secretions are commonly colonized by nosocomial GNB that rarely cause VAP, for example, Enterobacter species, Burkholderia (Pseudomonas) cepacia, and Sternotropmonas (Xanthomonas) maltophilia

Summary

Introduction

Empiric antimicrobial therapy of ventilator-associated pneumonia (VAP) should possess a high degree of activity against aerobic Gram-negative bacilli (GNB). Antibiotics with a high degree of P. aeruginosa activity are effective against other aerobic GNB causing VAP, that is, Escherichia coli, Klebsiella pneumoniae and Serratia marcescens. Culture of organisms from respiratory secretions in ventilated patients does not imply a causal relationship to fever, leukocytosis, and pulmonary infiltrates, and is not synonymous or diagnostic of VAP [1,2,3]. Colonization of respiratory secretions with Staphylococcus aureus, either methicillin-susceptible (MSSA) or methicillin-resistant (MRSA), is frequent, and the basis of National Nosocomial Infections Surveillance (NNIS) VAP data.

Results

Conclusion