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Table 1 A personal care bundle for optimizing antimicrobial treatment for intensive care unit patients with ventilator-associated pneumonia

From: Antibiotic stewardship in the intensive care unit

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.
  1. ESBL, extended-spectrum β-lactamase; GNB, Gram-negative bacilli; VAP, ventilator-associated pneumonia.