De-escalation therapy in ventilator-associated pneumonia

OBJECTIVE:To evaluate de-escalation of antibiotic therapy in patients with ventilator-associated pneumonia. DESIGN:Prospective observational study during a 43-month period. SETTING:Medical-surgical intensive care unit. PATIENTS:One hundred and fifteen patients admitted to the intensive care unit wit...

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Veröffentlicht in:Critical care medicine 2004-11, Vol.32 (11), p.2183-2190
Hauptverfasser: Rello, Jordi, Vidaur, Loreto, Sandiumenge, Alberto, Rodríguez, Alejandro, Gualis, Belen, Boque, Carmen, Diaz, Emili
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Sprache:eng
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Zusammenfassung:OBJECTIVE:To evaluate de-escalation of antibiotic therapy in patients with ventilator-associated pneumonia. DESIGN:Prospective observational study during a 43-month period. SETTING:Medical-surgical intensive care unit. PATIENTS:One hundred and fifteen patients admitted to the intensive care unit with clinical diagnosis of ventilator-associated pneumonia. All the episodes of ventilator-associated pneumonia received initial broad-spectrum coverage followed by reevaluation according to clinical response and microbiology. Quantitative cultures obtained by bronchoscopic examination or tracheal aspirates were used to modify therapy. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:One hundred and twenty-one episodes of ventilator-associated pneumonia were diagnosed. Change of therapy was documented in 56.2%, including de-escalation (the most frequent cause) in 31.4% (increasing to 38% if isolates were sensitive). Overall intensive care unit mortality rate was 32.2%. Inappropriate antibiotic therapy was identified in 9% of cases and was associated with 14.4% excess intensive care unit mortality. Quantitative tracheal aspirates and bronchoscopic samples (58 protected specimen brush and three bronchoalveolar lavage) were associated with 32.7% and 29.5% intensive care unit mortality and 29.3% and 34.4% de-escalation rate. De-escalation was lower (p < .05) in the presence of nonfermenting Gram-negative bacillus (2.7% vs. 49.3%) and in the presence of late-onset pneumonia (12.5% vs. 40.7%). When the pathogen remained unknown, half of the patients died and de-escalation was not performed. CONCLUSION:De-escalation was the most important cause of antibiotic modification, being more feasible in early-onset pneumonia and less frequent in the presence of nonfermenting Gram-negative bacillus. The impact of quantitative tracheal aspirates or bronchoscopic techniques was comparable in terms of mortality.
ISSN:0090-3493
1530-0293
DOI:10.1097/01.CCM.0000145997.10438.28