Determinants of prescription and choice of empirical therapy for hospital-acquired and ventilator-associated pneumonia

Abstract

the EU-VAP/CAP Study Group ABSTRACT: The objectives of this study were to assess the determinants of empirical antibiotic choice, prescription patterns and outcomes in patients with hospital-acquired pneumonia (HAP)/ ventilator-associated pneumonia (VAP) in Europe.We performed a prospective, observational cohort study in 27 intensive care units (ICUs) from nine European countries. 100 consecutive patients on mechanical ventilation for HAP, on mechanical ventilation .48 h or with VAP were enrolled per ICU.Admission category, sickness severity and Acinetobacter spp. prevalence .10% in pneumonia episodes determined antibiotic empirical choice. Trauma patients were more often prescribed nonanti-Pseudomonas cephalosporins (OR 2.68, 95% CI 1.50-4.78). Surgical patients received less aminoglycosides (OR 0.26, 95% CI 0.14-0.49). A significant correlation (p,0.01) was found between Simplified Acute Physiology Score II score and carbapenem prescription. Basal Acinetobacter spp. prevalence .10% dramatically increased the prescription of carbapenems (OR 3.5, 95% CI 2.0-6.1) and colistin (OR 115.7, 95% CI 6.9-1,930.9). Appropriate empirical antibiotics decreased ICU length of stay by 6 days (26.3¡19.8 days versus 32.8¡29.4 days; p50.04). The antibiotics that were prescribed most were carbapenems, piperacillin/tazobactam and quinolones. Median (interquartile range) duration of antibiotic therapy was 9 (6-12) days. Antimethicillin-resistant Staphylococcus aureus agents were prescribed in 38.4% of VAP episodes.Admission category, sickness severity and basal Acinetobacter prevalence .10% in pneumonia episodes were the major determinants of antibiotic choice at the bedside. Across Europe, carbapenems were the antibiotic most prescribed for HAP/VAP.

Azithromycin Attenuates Lung Inflammation in a Mouse Model of Ventilator-Associated Pneumonia by Multidrug-Resistant Acinetobacter baumannii

“…Recently, increasing numbers of drug-resistant A. baumannii strains have been identified. Among Gram-negative pathogens, Acinetobacter has the highest multidrug resistance rate (6), and among all bacterial pathogens, A. baumannii causes the highest rate of mortality from VAP (5). Furthermore, infections due to multidrug-resistant A. baumannii (MDRAB) strains are associated with a worse prognosis than infections caused by non-MDRAB strains (7,8).…”

“…A. baumannii causes pulmonary, urinary tract, bloodstream, and surgical wound infections (3,4). Ventilatorassociated pneumonia (VAP) is caused by A. baumannii more often than by other pathogens (5). Recently, increasing numbers of drug-resistant A. baumannii strains have been identified.…”

Meropenem Population Pharmacokinetics in Critically Ill Patients with Septic Shock and Continuous Renal Replacement Therapy: Influence of Residual Diuresis on Dose Requirements

“…eropenem is a broad-spectrum carbapenem with high levels of activity against Gram-positive and Gram-negative pathogens, including Pseudomonas aeruginosa, Acinetobacter spp., and anaerobes (1), and is one of the most prescribed antibiotics for the empirical treatment of severe infections (2). It exhibits optimal killing activity when the concentrations of the unbound fraction (f u ) of drug in plasma are maintained above the MIC of the bacteria for a certain percentage of dosing interval T (referred to as the percentage of the ƒ u T ϾMIC ), which in in vitro and in vivo animal studies has been defined to be about 40% (3).…”

Differences in hospital- and ventilator-associated pneumonia due to Staphylococcus aureus (methicillin-susceptible and methicillin-resistant) between Europe and Latin America: A comparison of the EUVAP and LATINVAP study cohorts

“…19 Therefore, duration of therapy should be based on individualized follow-up for resolution of signs and symptoms of infection. 20,21 Patients with advanced age, immuno-suppressors, acute kidney injury, nephrotoxic agents or severe sepsis/septic shock should avoid glycopeptides. 22,23 Paradoxically, benefit of vancomycin may be higher in patients with low glomerular filtration rate, due to drug accumulation.…”