Intrusion of antibacterial therapy protocol decreased mortality associated with VAP in severe trauma patients

Objective

To evaluate the efficiency of antibacterial protocol in severe trauma patients on the incidence and mortality of VAP.

Methods

This study was approved by the local ethics committee. A comparable analysis of incidence, attributive mortality (chi-square test) and pathogens of VAP in severe trauma patients was performed during two periods: 2001 (before introduction of protocol) and 2004 (after introduction of protocol) years. The developed protocol included:

• 1. Abandoning of antibiotic prophylaxis of VAP.

• 2. Intrusion criteria of early diagnostics of VAP.

• 3. Exclusion of all cefalosporine I-III generation, aminoglycosides and fluoroquinolones as empiric therapy of VAP.

• 4. Cefepime or cefoperazone/sulbactam (APACHE II score < 20) and carbapenems (APACHE II score > 20) were used as empiric therapy of VAP.

• 5. Efficacy of antibiotic treatment was evaluated after 48 hours.

• 6. Carbapenems and/or vancomycin was added if empiric therapy was inefficient. In the case of suspected diagnosis of VAP, microbiological analysis of broncoalveolar lavage fluid (BAL) was performed.

Results

In this study were included 499 patients with severe trauma and respiratory support for longer than 48 hours (2001, 220 patients and 2004, 279 patients). There was no difference in ISS and APACHE II score between the groups. The incidence of VAP was 10% in 2001 (22/220) and 9% in 2003 (25/279), difference not significant. The attributive mortality due to VAP in 2001 was 63% (14/22) and in 2004 was 24% (6/25) (P < 0.01). A widespread using of broad-spectrum antibiotics shifted the structure of nosocomial pathogens. We observed a decrease in the rate of MRSA and a significant increase in the rate of Klebsiella pneumoniae (from 0.6 to 18.1%, most strains were resistant to cefalosporine III) and Acinetobacter baumanii (from 1.2 to 12.3%, most strains were resistant to ceftazidime).

Conclusion

Intrusion of antibacterial protocol in patients with multiple trauma and VAP results in a decrease of attributive mortality (P < 0.01) without a change in incidence of VAP.