Update on management options in the treatment of nosocomial and ventilator assisted pneumonia: review of actual guidelines and economic aspects of therapy

Abstract

ObjectiveNosocomial or more exactly, hospital-acquired (HAP) and ventilator-associated pneumonia (VAP) are frequent conditions when treating intensive care unit (ICU) patients that are only exceeded by central line-associated bloodstream infections. In Germany, approximately 18,900 patients per year suffer from a VAP and another 4,200 from HAP. We therefore reviewed the current guidelines about HAP and VAP, from different sources, regarding the strategies to address individual patient risks and medication strategies for initial intravenous antibiotic treatment (IIAT).Material and methodsWe conducted an analysis of the recent guidelines for the treatment of HAP. The current guidelines of the American Thoracic Society, the treatment recommendations of the Paul-Ehrlich-Gesellschaft (PEG), the guidelines from the British Society for Antimicrobial Chemotherapy, the VAP guideline of the Canadian Critical Care trials group, as well as the new German S3-guideline for HAP were examined.ResultsAll guidelines are based on grading systems that assess the evidence underlying the recommendations. However, each guideline uses different grading systems. One common aspect of these guidelines is the risk assessment of the patients for decision making regarding IIAT. Most guidelines have different recommendations depending on the risk of the presence of multidrug resistant (MDR) bacteria. In guidelines using risk assessment, for low-risk patients (early onset, no MDR risk) aminopenicillins with beta-lactamase inhibitors (BLI), second or third generation cephalosporins, quinolones, or ertapenem are recommended. For patients with higher risk, imipenem, meropenem, fourth generation cephalosporins, ceftazidime or piperacillin/tazobactam are recommended. The PEG recommendations include a combination therapy in cases of very high risk (late onset, MDR risk, ICU, and organ failure) of either piperacillin/tazobactam, dori-, imi- or meropenem or cefepime or ceftazidime with ciprofloxacin, levofloxacin, fosfomycin or an aminoglycoside. For the treatment of HAP caused by methicillin-resistant Staphylococcus aureus (MRSA), either linezolid or vancomycin is recommended. With regard to the ZEPHyR-trial, linezolid has shown higher cure rates but, no difference in overall survival. Economic analyses show the relevance of guideline-adherent IIAT (GA-IIAT). Besides significantly better clinical outcomes, patients with GA-IIAT cause significantly lower costs (€28,033 versus (vs) €36,139) (P=0.006) and have a shorter length of stay in hospital (23.9 vs 28.3 days) (P=0.022).ConclusionWe conclude that most current treatment guidelines take into account the individual patient risk and that the correct choice of IIAT affects clinical as well as economical outcomes.

Prevalence of respiratory colonisations and related antibiotic resistances among paediatric tracheostomised patients of a long-term rehabilitation centre in Italy

“…Care for these patients is often complicated by antibiotic resistance, especially in countries where it occurs frequently [1]. All these factors have a significant clinical and economic impact in both short-and a long-term perspectives [23]. Thus, knowing the characteristics and relative burden of bacteria residing in a group of patients in one hospital unit may help identifying appropriate strategies to minimise their clinical impact.…”

“…At the same time these patients are exposed to intense interactions with healthcare professionals and relatives who may be a prominent source of pathogens [16][17][18][19]. The adequate management [20,21] of nosocomial pneumonia sustained by antibiotic-resistant bacteria is important for the consequences both on the clinical management choices for patients with ABI in ICUs [22] and for their long-term need of medical treatments [23]. To investigate these issues in a long-term perspective, we analysed a population of paediatric tracheostomised patients undergoing rehabilitation from ABI, focusing on the presence of bacteria during different stages of healthcare, their spectrum of antibiotic resistance and the development of respiratory symptoms.…”

A 2015 Update on Ventilator-Associated Pneumonia: New Insights on Its Prevention, Diagnosis, and Treatment

“…Inappropriate or delayed antibacterial treatment of VAP is important because it has been associated with increased VAP mortality [58,59]. The administration of empiric antimicrobial therapy should therefore be initiated as early as possible when VAP is suspected.…”

Clinical predictors and microbiology of ventilator-associated pneumonia in the intensive care unit: a retrospective analysis in six Italian hospitals

“…In Europe, a burden of 18,900 cases of VAP have been estimated to occur each year [2], with a mortality rate up to 50 % of cases in some reports and as high as 76 % in the most compromised patients, especially when multidrug-resistant pathogens are involved [3,4]. At the present time, VAP is considered to be the second most frequent nosocomial infection occurring in the ICU after central lines infections, and it may account for up to 25 % of all hospital-acquired infections in the ICU environment [1].…”