Jean Chastre1. 1. Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Paris, France. jean.chastre@psl.ap-hop-paris.fr
Abstract
BACKGROUND: Ventilator-associated pneumonia (VAP) is the most frequent intensive care unit (ICU)-acquired infection among patients receiving mechanical ventilation. Failure to initiate appropriate and adequate therapy (i.e., the etiologic organism is sensitive to the therapeutic agent, the dose is optimal, and the route of administration is correct) promptly in patients with VAP has been associated consistently with higher mortality rates. However, effective antimicrobial therapy for patients with true VAP can be achieved while avoiding excessive antibiotic use and the emergence of multidrug-resistant strains in the ICU. METHOD: Review of the pertinent English-language literature. RESULTS: Antimicrobial therapy for patients with VAP should follow a two-stage process. The first stage is identifying true pneumonia rapidly and starting therapy with an empirical regimen that is likely to be appropriate. In general, this requires using broad-spectrum antibiotics in all patients in whom there is a possibility that the etiologic pathogen could be difficult to treat (e.g., multi-drug-resistant pathogen). The second stage focuses on trying to achieve this objective without overusing and abusing antibiotics and combines a number of steps, such as stopping therapy in patients with a low probability of the disease, streamlining treatment once the etiologic agent is known, switching to monotherapy after three to five days, and shortening the duration of therapy to seven or eight days, as dictated by the patient's clinical response to therapy and information about the bacteriology of the infection. CONCLUSION: Although such a strategy seems a logical way to manage patients with VAP, data are still needed to determine how best to achieve this process.
BACKGROUND: Ventilator-associated pneumonia (VAP) is the most frequent intensive care unit (ICU)-acquired infection among patients receiving mechanical ventilation. Failure to initiate appropriate and adequate therapy (i.e., the etiologic organism is sensitive to the therapeutic agent, the dose is optimal, and the route of administration is correct) promptly in patients with VAP has been associated consistently with higher mortality rates. However, effective antimicrobial therapy for patients with true VAP can be achieved while avoiding excessive antibiotic use and the emergence of multidrug-resistant strains in the ICU. METHOD: Review of the pertinent English-language literature. RESULTS: Antimicrobial therapy for patients with VAP should follow a two-stage process. The first stage is identifying true pneumonia rapidly and starting therapy with an empirical regimen that is likely to be appropriate. In general, this requires using broad-spectrum antibiotics in all patients in whom there is a possibility that the etiologic pathogen could be difficult to treat (e.g., multi-drug-resistant pathogen). The second stage focuses on trying to achieve this objective without overusing and abusing antibiotics and combines a number of steps, such as stopping therapy in patients with a low probability of the disease, streamlining treatment once the etiologic agent is known, switching to monotherapy after three to five days, and shortening the duration of therapy to seven or eight days, as dictated by the patient's clinical response to therapy and information about the bacteriology of the infection. CONCLUSION: Although such a strategy seems a logical way to manage patients with VAP, data are still needed to determine how best to achieve this process.
Authors: Laura H Rosenberger; Tjasa Hranjec; Matthew D McLeod; Amani D Politano; Christopher A Guidry; Stephen Davies; Robert G Sawyer Journal: J Trauma Acute Care Surg Date: 2013-02 Impact factor: 3.313