Empiric Antibiotic Therapy in Hospital-Acquired and Ventilator-Associated Pneumonia

Patients in the intensive care unit with hospital-acquired and ventilator-associated pneumonia may be overtreated with empiric antibiotic treatment, according to a preliminary report published by the American Journal of Respiratory and Critical Care Medicine.

Researchers identified 316 patients admitted with a clinical and microbiological diagnosis of hospital-acquired (n=99), or ventilator-associated (n=217) pneumonia. Adherence to the empiric antimicrobial treatment guidelines, the predictive performance of the guidelines risk factors, and the observed antibiotic adequacy were analyzed.

The highest negative predictive values (NPV) were ≥5 days of hospitalization for ventilator-associated pneumonia (NPV, 80%), intravenous antibiotic use for hospital-acquired pneumonia (NPV, 69%), intravenous antibiotic use in general (NPV, 79%), methicillin-resistant (NPV, 91%), and multidrug-resistant Pseudomonas (NPV, 94%).

The most prevalent risk factors for multidrug resistance were ≥5 days hospitalization (n=240; 76%) and intravenous antibiotic use during the previous 90 days (n=197; 63%). 

The rate of clinician adherence to the 2016 Infectious Disease Society of America/American Thoracic Society (IDSA/ATS) guidelines for empiric antimicrobial treatment was between 19% and40%, with adequate empiric treatment used in 83% of patients overall and in 61% of patients with multidrug resistant pathogens. Moreover, it was found that if clinicians had treated patients based on the current guidelines, 3% of patients would have been undertreated and 60% of patients would have been overtreated.   

The investigators concluded that strictly following the 2016 IDSA/ATS guidelines for empiric antibiotic therapy of hospital-acquired and ventilator-associated pneumonia may lead to antibiotic overtreatment, and further validation of these guidelines, particularly in more diverse cohorts, is warranted. Clinicians should be aware of local microbial epidemiology to customize antibiotic treatment effectively for patients and limit unnecessary antibiotic use.

Reference

Ekren PK, Ranzani OT, Ceccato A, et al. Evaluation of the 2016 Infectious Diseases Society of America/American Thoracic Society guideline criteria for risk of multi-drug resistant pathogens in hospital-acquired and ventilator-associated pneumonia patients in the intensive care unit [published online September 13, 2017]. Am J Respir Crit Care Med. doi:10.1164/rccm.201708-1717LE