Appropriateness and delay to initiate therapy in ventilator-associated pneumonia

Abstract

Inappropriate therapy (IT) and delayed initiation of appropriate therapy (DIAT) result in inadequate therapy in patients with ventilator-associated pneumonia (VAP). The aim of the current study was to assess the impact of DIAT in VAP. A total of 76 mechanically ventilated patients with bacteriologically confirmed VAP were prospectively evaluated in the intensive care unit of six hospitals in Buenos Aires, Argentina.Appropriate therapy was defined as coverage of all the identified pathogens by the antimicrobial therapy administered at the time of VAP clinical diagnosis. The clinical pulmonary infection score was measured during the 3 days before, at the onset and during the days which followed the onset of VAP. A total of 24 patients received adequate therapy; mortality was 29.2%. The remaining 52 patients received either IT (n516) or DIAT (n536); the mortality was 63.5% combined, and 75.0 and 58.3% for IT and DIAT, respectively (statistically significant compared with adequate therapy).Inappropriate therapy and delayed initiation of appropriate therapy increased the mortality of ventilator-associated pneumonia. Patients with inappropriate therapy and/or delayed initiation of appropriate therapy had a more gradual increase in clinical pulmonary infection score than those receiving adequate therapy, and this increase was found to occur prior to the time of the clinical diagnosis.In conclusion, these findings might provide the rationale for a trial of earlier initiation of therapy, based on clinical grounds in an effort to improve the outcome of patients with ventilatorassociated pneumonia.

Pneumonia associada à ventilação mecânica

“…(6) In that study, mortality rates were lower among the patients who received appropriate antibiotic treatment within 24 h after the results of the CPIS had raised clinical suspicion of VAP. Further studies should be carried out in order to validate this concept.…”

Diretrizes brasileiras para tratamento das pneumonias adquiridas no hospital e das associadas à ventilação mecânica - 2007

“…Ao CPIS superior a (18) Neste caso, pacientes com baixa probabilidade clínica de PAVM e com CPIS < 6 no terceiro dia do tratamento empírico, a antibioticoterapia poderia ser descontinuada, sem que, com isso,ocorra aumento da taxa de mortalidade. Recentemente (19) , verificou-se que a utilização prospectiva e seriada da versão simplificada do CPIS, em pacientes submetidos à VM, identificou precocemente o desenvolvimento de PAVM, antes do aparecimento dos sinais clássicos da doença. Neste estudo, os pacientes tratados precocemente (dentro de 24 h da suspeita clínica pelo CPIS) e de forma adequada, apresentaram menor taxa de mortalidade.…”

The Role of Bronchoscopic Findings and Bronchoalveolar Lavage Fluid Cytology in Early Diagnosis of Ventilator-Associated Pneumonia

“…2 Besides pathogen virulence and host defense response, inappropriate or delayed initial antimicrobial therapy are factors associated with increased mortality. 3,4 Many clinical entities, such as alveolar hemorrhage, drug-induced lung toxicity, cardiogenic pulmonary edema, primary or secondary ARDS, collagen vascular diseases, and primary or metastatic lung cancer may mimic lower respiratory tract infections, but they differ from VAP in terms of management and overall prognosis. 5 However, no single clinical symptom or sign, imaging, or microbiological test can be used for the accurate early diagnosis of VAP.…”