Antibiotics For Ventilator-associated Pneumonia Research Articles

Effectiveness of First-Line Therapy with Old and Novel Antibiotics in Ventilator-Associated Pneumonia Caused by Carbapenem-Resistant Acinetobacter baumannii: A Real Life, Prospective, Observational, Single-Center Study.

Evidence-based, standard antibiotic therapy for ventilator-associated pneumonia (VAP) caused by carbapenem-resistant Acinetobacter baumannii (CRAB) is a relevant unmet clinical need in the intensive care unit (ICU). We aimed to evaluate the effectiveness of first-line therapy with old and novel CRAB active antibiotics in monomicrobial VAP caused by CRAB. A prospective, observational study was performed in a mixed non-COVID-19 ICU. The primary outcome measure was clinical failure upon first-line targeted therapy. Features independently influencing failure occurrence were also investigated via Cox proportional multivariable analysis. To account for the imbalance in antibiotic treatment allocation, a propensity score analysis with an inverse probability treatment weighting approach was adopted. Of the 90 enrolled patients, 34 (38%) experienced clinical failure. Compared to patients who experienced a clinical resolution of VAP, those who had clinical failure were of an older age (median age 71 (IQR 64-78) vs. 62 (IQR 52-69) years), and showed greater burden of comorbidities (median Charlson comorbidity index 8 (IQR 6-8) vs. 4 (IQR 2-6)), higher frequency of immunodepression (44% vs. 21%), and greater clinical severity at VAP onset (median SOFA score 10 (IQR 9-11) vs. 9 (IQR 7-11)). Lower rates of use of fast molecular diagnostics for nosocomial pneumonia (8.8% vs. 30.3%) and of timely CRAB active therapy administration (65% vs. 89%), and higher rates of colistin-based targeted therapy (71% vs. 46%) were also observed in patients who failed first-line therapy. Overall, CRAB active iv regimens were colistin-based in 50 patients and cefiderocol-based in 40 patients, both always combined with inhaled colistin. According to the backbone agent of first-line regimens, clinical failure was lower in the cefiderocol group, compared to that in the colistin group (25% vs. 48%, respectively). In multivariable Cox regression analysis, the burden of comorbid conditions independently predicted clinical failure occurrence (Charlson index aHR = 1.21, 95% CI = 1.04-1.42, p = 0.01), while timely targeted antibiotic treatment (aHR = 0.40, 95% CI = 0.19-0.84, p = 0.01) and cefiderocol-based first-line regimens (aHR = 0.38, 95% CI = 0.17-0.85, p = 0.02) strongly reduced failure risk. In patients with VAP caused by CRAB, timely active therapy improves infection outcomes and cefiderocol holds promise as a first-line therapeutic option.

Nebulized antibiotics for ventilator-associated pneumonia: methodological framework for future multicenter randomized controlled trials.

Although experimental evidence supports the use of nebulized antibiotics in ventilator-associated pneumonia (VAP), two recent multicenter randomized controlled trials (RCTs) have failed to demonstrate any benefit in VAP caused by Gram-negative bacteria (GNB). This review examines the methodological requirements concerning future RCTs. High doses of nebulized antibiotics are required to reach the infected lung parenchyma. Breath-synchronized nebulizers do not allow delivery of high doses. Mesh nebulizers perform better than jet nebulizers. Epithelial lining fluid concentrations do not reflect interstitial lung concentrations in patients receiving nebulized antibiotics. Specific ventilator settings for optimizing lung deposition require sedation to avoid patient's asynchrony with the ventilator. Future RCTs should compare a 3-5 day nebulization of amikacin or colistimethate sodium (CMS) to a 7-day intravenous administration of a new cephalosporine/ß-lactamase inhibitor. Inclusion criteria should be a VAP or ventilator-associated tracheobronchitis caused by documented extensive-drug or pandrug resistant GNB. If the GNB remains susceptible to aminoglycosides, nebulized amikacin should be administered at a dose of 40 mg/kg/day. If resistant to aminoglycosides, nebulized CMS should be administered at a dose of 15 millions international units (IU)/day. In VAP caused by pandrug-resistant GNB, 15 millions IU/day nebulized CMS (substitution therapy) should be compared with a 9 millions IU/day intravenous CMS.

New antibiotics for ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) caused by multidrug-resistant (MDR) bacteria represents a global emerging problem. Delayed prescription of an adequate treatment for VAP has been associated with higher morbidity and mortality. New molecules have been developed to face the need of compounds that are active against resistant Gram-positive and Gram-negative pathogens. The aim of this review is to summarize the current scenario of new therapeutic options for the treatment of VAP. A number of new antibiotics with activity against MDR have been recently approved for the treatment of VAP, and other agents are under investigation. In this review, the authors summarize the current therapeutic options for the treatment of VAP that showed promising implications for clinical practice, including new compounds belonging to old antibiotic classes (e.g., ceftolozane/tazobactam, ceftazidime/avibactam meropenem/vaborbactam, imipenem/relebactam, tedizolid, cefiderocol, eravacycline, and plazomicin) and novel chemical classes, such as murepavadin. Nebulized antibiotics that are currently in development for the treatment of pneumonia in mechanically ventilated patients are also presented. Newly approved and investigational drugs for the treatment of VAP are expected to offer many advantages for the management of patients with respiratory infections caused by MDR. Promising characteristics of new compounds include high activity against both methicillin-resistant Staphylococcus aureus and MDR Gram-negative bacteria and a favorable safety profile.

Recommendations for aerosolized antibiotics in ventilator-associated pneumonia and ventilator-associated tracheobronchitis: too little and too late?

Recommendations for aerosolized antibiotics in ventilator-associated pneumonia and ventilator-associated tracheobronchitis: too little and too late?

Ventilator-Associated Pneumonia (VAP): Clinical Strategies, Treatment Challenges and Economic Concerns

The clinical and economic features of Ventilator-Associated Pneumonia (VAP) are quite unclear, with an extensive array of values and contradictory results. The real challenge in this connection is to present the real estimate of the clinical and associated economic consequences of VAP. In developing countries like Pakistan, it is important to formulate an optimal institutional antimicrobial policy that can be used as a guide for empirical/prophylactic and specific therapies of antibiotics in VAP with more rational approach to lessen the rates of mortality and morbidity, decline the length of treatment and hospitalization and the significant impact in prevention of development of multidrug resistant strains and cost reduction.

Antibiotics for ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is a significant cause of morbidity and mortality, complicating the medical course of approximately 10% of mechanically-ventilated patients, with an estimated attributable mortality of 13%. To treat VAP empirically, the American Thoracic Society currently recommends antibiotic therapy based on the patients' risk of colonisation by an organism with multidrug resistance. The selection of initial antibiotic therapy in VAP is important, as inappropriate initial antimicrobial treatment is associated with higher mortality and longer hospital stay in intensive care unit (ICU) patients.While guidelines exist for the antibiotic treatment of hospital-acquired pneumonia (HAP) from the American Thoracic Society and the British Society for Antimicrobial Chemotherapy, there are many limitations in the quality of available evidence. This systematic review aimed to summarise the results of all randomised controlled trials (RCTs) that compare empirical antibiotic regimens for VAP. The primary objective of this review was to assess the effect of different empirical antimicrobial therapies on the survival and clinical cure of adult patients with ventilator-associated pneumonia (VAP). Secondary objectives included reporting the incidence of adverse events, new superinfections, length of hospital stay, and length of intensive care unit (ICU) stay associated with these therapies. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, CINAHL and Web of Science to December 2015; we searched ClinicalTrials.gov to September 2016. Two review authors independently assessed RCTs comparing empirical antibiotic treatments of VAP in adult patients, where VAP was defined as new-onset pneumonia that developed more than 48 hours after endotracheal intubation. Physicians and researchers were not required to be blinded for inclusion in this review. Two review authors independently extracted study data. We pooled studies and analysed them in two ways. We examined monotherapy, or a single experimental antimicrobial drug, versus combination therapy, or multiple experimental antimicrobial drugs. We also examined carbapenem therapy versus non-carbapenem therapy. We included 12 studies with 3571 participants. All included studies examined the empiric use of one antimicrobial regimen versus another for the treatment of adults with VAP, but the particular drug regimens examined by each study varied. There was potential for bias because some studies did not report outcomes for all participants. All but one study reported sources of funding or author affiliations with pharmaceutical companies.We found no statistical difference in all-cause mortality between monotherapy and combination therapy (N = 4; odds ratio (OR) monotherapy versus combination 0.97, 95% confidence interval (CI) 0.73 to 1.30), clinical cure (N = 2; OR monotherapy versus combination 0.88, 95% CI 0.56 to 1.36), length of stay in ICU (mean difference (MD) 0.65, 95% CI 0.07 to 1.23) or adverse events (N = 2; OR monotherapy versus combination 0.93, 95% CI 0.68 to 1.26). We downgraded the quality of evidence for all-cause mortality, adverse events, and length of ICU stay to moderate for this comparison. We determined clinical cure for this comparison to be of very low-quality evidence.For our second comparison of combination therapy with optional adjunctives only one meta-analysis could be performed due to a lack of trials comparing the same antibiotic regimens. Two studies compared tigecycline versus imipenem-cilastatin for clinical cure in the clinically evaluable population and there was a statistically significant increase in clinical cure for imipenem-cilastatin (N = 2; OR tigecycline versus imipenem-cilastatin 0.44, 95% CI 0.23 to 0.84). Of importance, this effect was due to a single study.We found no statistical difference in all-cause mortality between carbapenem and non-carbapenem therapies (N = 1; OR carbapenem versus non-carbapenem 0.59, 95% CI 0.30 to 1.19) or adverse events (N = 3; OR carbapenem versus non-carbapenem 0.78, 95% CI 0.56 to 1.09), but we found that carbapenems are associated with a statistically significant increase in the clinical cure (N = 3; OR carbapenem versus non-carbapenem 1.53, 95% CI 1.11 to 2.12 for intention-to-treat (ITT) analysis and N = 2; OR carbapenem versus non-carbapenem 2.29, 95% CI 1.19 to 4.43 for clinically evaluable patients analysis). For this comparison we downgraded the quality of evidence for mortality, and clinical cure (ITT and clinically evaluable populations) to moderate. We determined the quality of evidence for adverse events to be low. We did not find a difference between monotherapy and combination therapy for the treatment of people with VAP. Since studies did not identify patients with increased risk for multidrug-resistant bacteria, these data may not be generalisable to all patient groups. However, this is the largest meta-analysis comparing monotherapy to multiple antibiotic therapies for VAP and contributes further evidence to the safety of using effective monotherapy for the empiric treatment of VAP.Due to lack of studies, we could not evaluate the best antibiotic choice for VAP, but carbapenems as a class may result in better clinical cure than other tested antibiotics.

Individualized antibiotic strategies.

Infections are common complications in critically ill patients and are frequently treated with antibiotics. Unfortunately, delivery of optimal therapy is complicated because efficacy of antimicrobials is influenced by the timing of treatment initiation, the use of combination therapy, and the optimization of drug dosing. Early diagnosis of infection is mandatory to provide a rapid and appropriate antibiotic therapy. The presence of less susceptible strains, in particular for hospital-acquired infections, or patients with severe disease, such as the presence of septic shock, may need combination antibiotic therapy. Antibiotic pharmacokinetics, notably volume of distribution and total body clearance, are significantly altered in these critically ill patients and can influence the attainment of adequate circulating levels when standard dosage regimens are administered. Higher dosing should be considered in such patients, although in case of renal impairment and reduced clearance, drug accumulation could also result in some side-effects. Nebulized antibiotics may provide a better clinical response than systemic antibiotics in ventilator-associated pneumonia because of multidrug-resistant pathogens. The optimal use of antibiotics in the management of severe infections is an important challenge for ICU physicians. Antimicrobial therapy needs to be individualized according to specific patient characteristics, infecting organisms, and susceptibility patterns.

The use of inhaled antibiotic therapy in the treatment of ventilator-associated pneumonia and tracheobronchitis: a systematic review.

BackgroundVentilator-associated respiratory infections (tracheobronchitis, pneumonia) contribute significant morbidity and mortality to adults receiving care in intensive care units (ICU). Administration of broad-spectrum intravenous antibiotics, the current standard of care, may have systemic adverse effects. The efficacy of aerosolized antibiotics for treatment of ventilator-associated respiratory infections remains unclear. Our objective was to conduct a systematic review of the efficacy of aerosolized antibiotics in the treatment of ventilator-associated pneumonia (VAP) and tracheobronchitis (VAT), using the Cochrane Collaboration guidelines.MethodsWe conducted a search of three databases (PubMed, Web of Knowledge and the Cochrane Collaboration) for randomized, controlled trials studying the use of nebulized antibiotics in VAP and VAT that measured clinical cure (e.g., change in Clinical Pulmonary Infection Score) as an outcome measurement. We augmented the electronic searches with hand searches of the references for any narrative review articles as well as any article included in the systematic review. Included studies were examined for risk of bias using the Cochrane Handbook’s “Risk of Bias” assessment tool.ResultsSix studies met full inclusion criteria. For the systemic review’s primary outcome (clinical cure), two studies found clinically and statistically significant improvements in measures of VAP cure while four found no statistically significant difference in measurements of cure. No studies found inferiority of aerosolized antibiotics. The included studies had various degrees of biases, particularly in the performance and detection bias domains. Given that outcome measures of clinical cure were not uniform, we were unable to conduct a meta-analysis.ConclusionsThere is insufficient evidence for the use of inhaled antibiotic therapy as primary or adjuvant treatment of VAP or VAT. Additional, better-powered randomized-controlled trials are needed to assess the efficacy of inhaled antibiotic therapy for VAP and VAT.Electronic supplementary materialThe online version of this article (doi:10.1186/s12890-016-0202-8) contains supplementary material, which is available to authorized users.

Nebulized colistin for treatment of ventilator-associated pneumonia caused by multidrug-resistant Gram-negative bacteria: we still need to straighten out the dose!

We applaud the extensive systematic review and meta-analysis by Zampieri and colleagues on inhaled antibiotics for ventilator-associated pneumonia (VAP) [1] but would like to add some comments regarding inhaled colistin for treatment of VAP caused by multidrug-resistant Gram-negative bacteria (MDR-GNB). In patients with cystic fibrosis, the equivalent of 160 mg colistimethate sodium (CMS) produced high and therapeutic endobronchial concentrations [2]. However, to be effective in VAP caused by MDR-GNB, colistin must attain pulmonary concentrations that substantially exceed minimal plasma inhibitory levels for these microorganisms. Colistin aerosols used in the predominantly retrospective and observational studies summarized by Zampieri and colleagues contained CMS doses ranging from 80 to 300 mg [1]. These doses may be insufficient to grant any significant or additional therapeutic value to inhaled colistin, especially when used together with intravenous antibiotics. Indeed, a total daily inhaled dose of 240 mg CMS was found to be inadequate to treat lung infection caused by MDR-GNB [3]. A recent review recommended inhalation of 160 mg CMS every 8 h for severe pulmonary infections [4]. Finally, a daily dose of 1,200 mg inhaled CMS used in monotherapy or associated with a 3-day course of intravenous aminoglycosides cured VAP caused by MDR-GNB as effectively as VAP caused by β-lactam susceptible GNB [5]. In contrast with intravenous administration, high doses of nebulized colistin are not associated with an increased risk of kidney injury, even when given for a prolonged period of time [5]. We strongly salute aerosolized colistin as an important alternative or adjunct therapy to treat VAP caused by MDR-GNB, provided that the daily inhaled dose is sufficiently high.

Concordance between a new molecular real-time approach and traditional culture in suspected VAP patients

Early microbiological documentation may reduce attributable mortality and excessive use of broad-spectrum antibiotics in ventilator-associated pneumonia (VAP). Using bronchoalveolar lavage (BAL) and endotracheal aspirates (ETA), we studied a new molecular biology-based approach to detect and quantify bacteria in less than 3 hours. This prospective multicenter trial aimed at comparing the microbiological results obtained using this molecular protocol (easyMAG® system) and semiquantitative culture in suspected VAP.

Lung Ultrasonography for the Detection of Anesthesia-induced Lung Atelectasis

We have read with great interest the article by Acosta et al.1 exploring the use of lung ultrasound as a mean to detect intraoperative atelectasis. However, despite their statement to the contrary, the occurrence of B lines in the setting of atelectasis has already been described by others. Although B lines were initially thought to originate from the interaction of the ultrasound beam with thickened subpleural interlobular septa found in alveolar-interstitial pathologies,2 recent work has challenged this hypothesis. In an elegant series of experiments, Soldati et al.3–5 have shown that B lines are observed when the ultrasound beam interacts at the pleural surface with lung tissue of a specific density. Although this can occur with the replacement of subpleural air by an ultrasound-conductive substance (e.g., water, pus, blood, and fibrous tissue), the withdrawal of air (e.g., resorption atelectasis) will also lead to the genesis of B lines. Demonstrating this last point, in an ex vivo animal model of graded atelectasis, B lines were observed in increasing numbers with increasing atelectasis. Pathologic examination of the excised lungs showed diffusely compressed alveoli mixed with sporadic areas of normally expanded distal air spaces.5The study by Acosta et al. comes at an interesting moment. The recent publication of two randomized controlled trials6,7 exploring the impact of intraoperative mechanical ventilation parameters on postoperative pulmonary complications has generated much interest.8 Although some have linked the negative results of the PROVHILO (PROtective Ventilation using HIgh versus LOw positive end-expiratory pressure) trial to a lack of regular recruitment maneuvers and a positive end-expiratory pressure set too high,9 others blame the use of inappropriately high tidal volumes in the control group for the positive results in the IMPROVE (Intraoperative PROtective VEntilation) trial.10 In the absence of imagery supporting claims of atelectasis or overdistention, the culprits usually blamed for the development of postoperative pulmonary complications, it is unlikely this question will be resolved before more data becomes available. Interestingly, recent anesthesiology literature has demonstrated the advantage of hemodynamic optimization11 championing the concept that individualization is preferable to a “one size fits all” approach. Likewise, individualization of mechanical ventilation parameters might be an interesting avenue to explore if we wish to decrease the occurrence of postoperative respiratory complications. This hypothesis is supported by spiral computed tomography studies reporting significant interpatient variability in the amount of atelectasis induced by general anesthesia.12,13 Therefore, we believe that bedside monitoring to detect lung atelectasis or overdistention is needed. Although magnetic resonance imaging and computed tomography fulfill this requirement, they cannot be used in an intraoperative setting except in specially designed operating rooms and could not realistically be repeated throughout a procedure. Because lung ultrasonography can be performed at the bedside and is devoid of any ionizing radiation, the present study by Acosta et al., although interesting in and of itself, is an important milestone toward establishing lung ultrasonography as a tool to optimize intraoperative mechanical ventilation parameters. Other investigators have described loss of aeration scales that have allowed the study of the therapeutic effects of antibiotics in ventilator-associated pneumonia,14 the effect of different levels of positive end-expiratory pressure in patients with acute respiratory distress syndrome on lung reexpansion15 and the detection of patients likely to fail extubation after a successful spontaneous breathing trial.16 Although not developed specifically for the diagnosis and monitoring of anesthesia-induced atelectasis, the use of these scales would have been an interesting addition to the study by Acosta et al. Whether to optimize intraoperative mechanical ventilation parameters or to assist anesthesiologists in the care of hypoxemic patients, lung ultrasonography is likely to have a bright future in our operating rooms.Supported by Grant of the Fondation 2013, Fondation d’anesthésiologie et réanimation du Québec; Grant of the Fonds de développement 2014, Département d’anesthésiologie, Université de Montréal.The authors declare no competing interests.

Effectiveness of Adjunctive Inhaled Colistin in Treatment of Ventilator Associated Pneumonia

Ventilator-Associated pneumonia (VAP) represents a major health problem in mechanically ventilated patients in intensive care units (ICUs). Aerosolized colistin could represent an adjunctive treatment to intravenous antibiotics in VAP. To evaluate the safety and efficacy of adjunctive inhaled colistin in treatment of patients with Gram-negative VAP compared to the conventional intravenous antibiotic regimen alone. This prospective randomized controlled study was conducted from July 2013 to August 2014 at Kasr El-Aini Medical ICU. Our study included a total number of 50 cases with VAP randomly assigned into two equal groups; a study group (who received the conventional systemic IV antibiotic regimen plus adjunctive inhaled colistin) and a control group (who received the conventional systemic IV antibiotic regimen alone). 76% of the patients were men with severe underlying co-morbidities. The main causative organisms of VAP were Klebsiella spp. (32%), Acinetobacter spp. (26%) and Pseudomonas spp. (24%). Patients in the study group had significantly more favourable microbiological outcome when compared with patients in the control group (80% versus 52%, P=0.03). No adverse effects related to inhaled colistin (nephrotoxicity, neurotoxicity, bronchoconstriction, cough, apnea or chest tightness) were recorded. Inhaled colistin seems to be safe and efficient as an adjunctive treatment for patients with Gram-negative VAP.

Probiotics for preventing ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is common in intensive care units (ICUs). Some evidence indicates that probiotics may reduce the incidence of VAP. Several additional published studies have demonstrated that probiotics are safe and efficacious in preventing VAP in ICUs. We aimed to systematically summarise the results of all available data to generate the best evidence for the prevention of VAP. To evaluate the effectiveness and safety of probiotics for preventing VAP. We searched CENTRAL (2014, Issue 8), MEDLINE (1948 to September week 1, 2014) and EMBASE (2010 to September 2014). Randomised controlled trials (RCTs) comparing probiotics with placebo or another control (excluding RCTs that use probiotics in both study groups) to prevent VAP. Two review authors independently assessed eligibility and the quality of trials, and extracted data. We included eight RCTs, with 1083 participants. All studies compared a form of probiotic (Lactobacillus casei rhamnosus; Lactobacillus plantarum; Synbiotic 2000FORTE; Ergyphilus; combination Bifidobacterium longum + Lactobacillus bulgaricus + Streptococcus thermophilus) versus a control group (placebo; glutamine; fermentable fibre; peptide; chlorhexidine). The analysis of all RCTs showed that the use of probiotics decreased the incidence of VAP (odds ratio (OR) 0.70, 95% confidence interval (CI) 0.52 to 0.95, low quality evidence). However, the aggregated results were uncertain for ICU mortality (OR 0.84, 95% CI 0.58 to 1.22 very low quality evidence), in-hospital mortality (OR 0.78, 95% CI 0.54 to 1.14, very low quality evidence), incidence of diarrhoea (OR 0.72, 95% CI 0.47 to 1.09, very low quality evidence), length of ICU stay (mean difference (MD) -1.60, 95% CI -6.53 to 3.33, very low quality evidence), duration of mechanical ventilation (MD -6.15, 95% CI -18.77 to 6.47, very low quality evidence) and antibiotic use (OR 1.23, 95% CI 0.51 to 2.96, low quality evidence). Antibiotics for VAP were used for a shorter duration (in days) when participants received probiotics in one small study (MD -3.00, 95% CI -6.04 to 0.04). However, the CI of the estimated effect was too wide to exclude no difference with probiotics. There were no reported events of nosocomial probiotic infections in any included study.The overall methodological quality of the included studies, based on our 'Risk of bias' assessments, was moderate with half of the included studies rated as a 'low' risk of bias; however, we rated four included studies as a 'high' risk of bias across one or more of the domains. The study limitations, differences in probiotics administered and participants, and small sample sizes across the included studies mean that the power to detect a trend of overall effect may be limited and chance findings cannot be excluded.To explore the influence of some potential confounding factors in the studies, we conducted an intention-to-treat (ITT) analysis, which did not change the inference of per-protocol analysis. However, our sensitivity analysis did not indicate a significant difference between groups for instances of VAP. Evidence suggests that use of probiotics is associated with a reduction in the incidence of VAP. However, the quality of the evidence is low and the exclusion of the one study that did not provide a robust definition of VAP increased the uncertainty in this finding. The available evidence is not clear regarding a decrease in ICU or hospital mortality with probiotic use. Three trials reported on the incidence of diarrhoea and the pooled results indicate no clear evidence of a difference. The results of this meta-analysis do not provide sufficient evidence to draw conclusions on the efficacy and safety of probiotics for the prevention of VAP in ICU patients.

Is a Strategy Based on Routine Endotracheal Cultures the Best Way to Prescribe Antibiotics in Ventilator-Associated Pneumonia?

The objectives of this study were to evaluate if a strategy based on routine endotracheal aspirate (ETA) cultures is better than using the American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines to prescribe antimicrobials in ventilator-associated pneumonia (VAP). This was a prospective, observational, cohort study conducted in a 15-bed ICU and comprising 283 patients who were mechanically ventilated for ≥48 h. Interventions included twice-weekly ETA; BAL culture was done if VAP was suspected. BAL (collected at the time of VAP) plus ETA cultures (collected≤7 days before VAP) (n=146 different pairs) were defined. We compared two models of 10 days of empirical antimicrobials (ETA-based vs ATS/IDSA guidelines-based strategies), analyzing their impact on appropriateness of therapy and total antimicrobial-days, using the BAL result as the standard for comparison. Complete ETA and BAL culture concordance (identical pathogens or negative result) occurred in 52 pairs; discordance (false positive or false negative) in 67, and partial concordance in two. ETA predicted the etiology in 62.4% of all pairs, in 74.0% of pairs if ETA was performed≤2 days before BAL, and in 46.2% of pairs if ETA was performed 3 to 7 days before BAL (P=.016). Strategies based on the ATS/IDSA guidelines and on ETA results led to appropriate therapy in 97.9% and 77.4% of pairs, respectively (P<.001). The numbers of antimicrobial-days were 1,942 and 1,557 for therapies based on ATS/IDSA guidelines and ETA results, respectively (P<.001). The ATS/IDSA guidelines-based approach was more accurate than the ETA-based strategy for prescribing appropriate, initial, empirical antibiotics in VAP, unless a sample was available≤2 days of the onset of VAP. The ETA-based strategy led to fewer days on prescribed antimicrobials.

Away from Home

Journal of Palliative MedicineVol. 15, No. 12 Personal ReflectionAway from HomeRichard J. LinRichard J. LinSearch for more papers by this authorPublished Online:3 Dec 2012https://doi.org/10.1089/jpm.2012.0234AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Away from Home." , 15(12), pp. 1392–1393FiguresReferencesRelatedDetails Volume 15Issue 12Dec 2012 InformationCopyright 2012, Mary Ann Liebert, Inc.To cite this article:Richard J. Lin.Away from Home.Journal of Palliative Medicine.Dec 2012.1392-1393.http://doi.org/10.1089/jpm.2012.0234Published in Volume: 15 Issue 12: December 3, 2012PDF download