Antibiotic stewardship items | Rationale |
---|---|
Step 1: Obtain bronchoalveolar specimens for Gram staining and cultures before introducing new antibiotics. | Every effort should be made to obtain reliable specimens from the specific infection site for direct microscope examination and cultures in order to enable de-escalation. |
Step 2: Start antibiotics less than 2 hours after bronchoalveolar lavage. | Time to appropriate antimicrobial administration is a major outcome determinant for intensive care unit patients with severe bacterial infections. |
Step 3: Start therapy using broad-spectrum antibiotics unless no risk factors for resistant pathogens are present. | Owing to the emergence of multiresistant GNB (for example, Pseudomonas aeruginosa and ESBL-producing GNB), empirical broad-spectrum antibiotics are justified for most patients with clinically suspected VAP. |
Step 4: Stop therapy on day 3 if infection becomes unlikely. | Antibiotics can be discontinued very early when VAP diagnosis becomes highly unlikely based on negative cultures and clinical course and the elimination of an extrapulmonary infection. |
Step 5: Use pharmacokinetic-pharmacodynamic data to optimize treatment. | Clinical and bacteriological outcomes can be improved by optimizing the therapeutic regimen according to pharmacokinetic-pharmacodynamic properties of the selected agents. |
Step 6: Streamline antibiotic therapy by using narrower-spectrum antibiotics once the etiological agent is identified. | For many patients with VAP, including those with late-onset infections, therapy can be narrowed once respiratory tract and blood culture results become available, either because an anticipated bacterium (for example, P. aeruginosa, Acinetobacter spp., or methicillin-resistant Staphylococcus aureus) was not recovered or because the isolated pathogen is sensitive to a narrower-spectrum antibiotic than that used initially. |
Step 7: Switch to monotherapy on days 3 to 5. | Using a two-antibiotic regimen for more than 3 to 5 days has no clinical benefits, provided that initial therapy was appropriate, the clinical course evolves favorably, and microbiological data exclude difficult-to-treat microorganisms. |
Step 8: Shorten the treatment duration based on procalcitonin kinetics. | Shorter antibiotic administration for patients with VAP has achieved good outcomes with less antibiotic consumption. Prolonged therapy leads to colonization with antibiotic-resistant bacteria, which may precede recurrent VAP episodes. |