Institution-specific guidelines for the management of ventilator-associated pneumonia

Introduction

ATS/IDSA [1] guidelines recommend consideration of local microbiologic data when selecting empiric treatment for ventilator-associated pneumonia (VAP) and broad-spectrum empiric therapy for patients with pneumonia caused by MDR pathogens. The purpose was to use local microbiologic data to develop institution-specific guidelines for VAP.

Methods

We prospectively recorded local microbiologic and susceptibility data in our ICU. Respiratory specimens were tracheal aspirates in all cases and were evaluated by quantitative criteria.

Results

We had 40 episodes (2,247 ventilator-days) of VAP (40/133 patients) and 45 isolates. In early-onset pneumonia (≤5 days, eight episodes, three with two isolates): six Acinetobacter baumannii: meropenem, colistin, gentamicin (five); three Pseudomonas aeruginosa: piperacillin, aztreonam, imipenem, ceftazidime, colistin, ciprofloxacin, cefepime, meropenem, aminoglycosides; one Klebsiella pneumoniae: meropenem, colistin, tetracycline; Fungi 1: no susceptibility results. In late-onset pneumonia (>5 days, 32 episodes, two with two isolates): 25 A. baumannii: four to amoxicillin-clavulanic, ceftazidime, piperacillin-tazobactam, aztreonam, imipenem, colistin, ciprofloxacin, cefepime, meropenem, aminoglycosides, 19 to meropenem, gentamicin, colistin, tetracycline and two to colistin; four P. aeruginosa: two to piperacillin-tazobactam, two to colistin; one K. pneumoniae: piperacillin-tazobactam, aztreonam, imipenem, ceftazidime, colistin, ciprofloxacin, cefepime, meropenem, aminoglycosides, amoxicillin-clavulanic; Fungi 1: no susceptibility results and three unspecified isolates.

Excluding fungi and unspecified isolates, we had 8/45 multisensitive isolates and 32/45 isolates sensitive to colistin (32), meropenem (26) and gentamicin (21). According to these data in early and late VAP the most adequate therapeutic combination to cover possible pathogens is meropenem + colistin. Using this combination we cover all possible pathogens and then de-escalate according to susceptibility results. Following the ATS/IDSA guidelines we would cover only 8/45 isolates.

Conclusion

ATS/IDSA [1] guidelines may not be applicable in all institutions or countries and thus clinicians should incorporate local microbiologic data into institution-specific guidelines [2].