Empiric, Broad-Spectrum Antibiotic Therapy with an Aggressive De-Escalation Strategy Does Not Induce Gram-Negative Pathogen Resistance in Ventilator-Associated Pneumonia

Hibbard, Michael L.; Kopelman, Tammy R.; O’Neill, Patrick J.; Maly, Tyler J.; Matthews, Marc R.; Cox, Jordy C.; Vail, Sydney J.; Quan, Asia N; Drachman, David A.

doi:10.1089/sur.2009.046

Cited by 11 publications

(6 citation statements)

References 21 publications

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“…Delaying treatment and failing to cover patients' causative pathogens are both associated with higher mortality rates Conversely, broader coverage and longer treatment courses increase the risks of adverse drug effects, C. difficile infections, and antimicrobial resistance [191,192]. The generally recommended compromise is to pair early and aggressive treatment with early and aggressive de-escalation (see section XXIII) [68,84,120,[193][194][195][196][197].…”

Section: Rationale For the Recommendationsmentioning

confidence: 99%

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

Kalil

Metersky

Klompas

et al. 2016

Clinical Infectious Diseases

2,736

2,647

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It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.

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Section: Rationale For the Recommendationsmentioning

confidence: 99%

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

Kalil

Metersky

Klompas

et al. 2016

Clinical Infectious Diseases

2,736

2,647

View full text Add to dashboard Cite

show abstract

“…The guidelines suggest that therapy can be narrowed to a single agent if lower respiratory tract cultures do not demonstrate resistant pathogens. It has been shown that this approach of deescalation contributes to the preservation of antimicrobial susceptibilities (8,110).…”

Section: Hospital-acquired Pneumoniamentioning

confidence: 99%

Combination Therapy for Treatment of Infections with Gram-Negative Bacteria

2012

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SUMMARY Combination antibiotic therapy for invasive infections with Gram-negative bacteria is employed in many health care facilities, especially for certain subgroups of patients, including those with neutropenia, those with infections caused by Pseudomonas aeruginosa , those with ventilator-associated pneumonia, and the severely ill. An argument can be made for empiric combination therapy, as we are witnessing a rise in infections caused by multidrug-resistant Gram-negative organisms. The wisdom of continued combination therapy after an organism is isolated and antimicrobial susceptibility data are known, however, is more controversial. The available evidence suggests that the greatest benefit of combination antibiotic therapy stems from the increased likelihood of choosing an effective agent during empiric therapy, rather than exploitation of in vitro synergy or the prevention of resistance during definitive treatment. In this review, we summarize the available data comparing monotherapy versus combination antimicrobial therapy for the treatment of infections with Gram-negative bacteria.

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“…A collegiate body, including intensive care specialists, clinical microbiologists and infectious diseases specialists, performed daily reviews of antibiotic treatments according to clinical evolution and microbiological results. De-escalation was carried out in accordance with international definitions [14,15].…”

Section: Methodsmentioning

confidence: 99%

Trimetoprim-sulfametoxazole in ventilator-associated pneumonia: a cohort study

Strazzulla

Postorino

Purcarea

et al. 2019

Eur J Clin Microbiol Infect Dis

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To evaluate the effectiveness of trimetoprim-sulfametoxazole (TMP-SMX) for treatment of ventilator-associated pneumonia (VAP). A retrospective cohort study including patients with VAP from 2011 to 2017. Two groups were analysed: TMP-SMX group, including patients who had received TMP-SMX (as first-line and as de-escalation), and No-TMP-SMX group, including patients who had not received TMP-SMX treatment. Primary clinical outcome was mortality at 30 days from starting the antibiotic treatment (T30). Secondary outcomes were mortality at end of treatment (EoT), day survival at T30, and acquisition of multidrug-resistant bacteria during hospitalization in intensive care unit. Eighty cases of VAP were included and devised into two groups: No-TMP-SMX (31/80; 39%) and TMP-SMX (49/80; 61%). Univariate analysis showed no significant differences were found when the TMP-SMX group was compared with the No-TMP-SMX group, except for frequency of male gender (p = 0.025). No significant statistical correlations between mortality at T30 and individual factors were detected by the multivariate model. No cases of either severe allergy or Clostridium difficile disease were reported in the TMP-SMX and No-TMP-SMX groups. TMP-SMX treatment was not associated with higher mortality at EoT and T30 in comparison with the No-TMP-SMX group. TMP-SMX had a good safety profile, in terms of ecology (acquisition of MDR bacteria and Clostridium difficile disease) and clinical management (no allergy events).

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Empiric, Broad-Spectrum Antibiotic Therapy with an Aggressive De-Escalation Strategy Does Not Induce Gram-Negative Pathogen Resistance in Ventilator-Associated Pneumonia

Abstract: In our SICU, early, empiric broad-spectrum VAP therapy followed by de-escalation to pathogen-specific agents did not alter antimicrobial resistance and is a valid practice. Further, our compliance with de-escalation practices was higher than published rates.

Cited by 11 publications

References 21 publications

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

Combination Therapy for Treatment of Infections with Gram-Negative Bacteria

Trimetoprim-sulfametoxazole in ventilator-associated pneumonia: a cohort study

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