De-escalation therapy in ventilator-associated pneumonia

Crit Care Med. 2004 Nov;32(11):2183-90. doi: 10.1097/01.ccm.0000145997.10438.28.

Abstract

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.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Algorithms
  • Anti-Bacterial Agents / therapeutic use*
  • Bronchoalveolar Lavage Fluid / microbiology
  • Bronchoscopy
  • Comorbidity
  • Critical Care / methods
  • Critical Care / standards
  • Cross Infection / diagnosis
  • Cross Infection / drug therapy*
  • Cross Infection / etiology*
  • Cross Infection / mortality
  • Decision Trees
  • Empirical Research
  • Evidence-Based Medicine
  • Female
  • Hospital Mortality
  • Humans
  • Infection Control
  • Male
  • Microbial Sensitivity Tests
  • Middle Aged
  • Pneumonia, Bacterial / diagnosis
  • Pneumonia, Bacterial / drug therapy*
  • Pneumonia, Bacterial / etiology*
  • Pneumonia, Bacterial / mortality
  • Practice Guidelines as Topic
  • Prospective Studies
  • Respiration, Artificial / adverse effects*
  • Risk Factors
  • Sputum / microbiology
  • Time Factors
  • Treatment Outcome

Substances

  • Anti-Bacterial Agents