title: De-escalation therapy in ventilator-associated pneumonia.
abstract: OBJECTIVE
  To evaluate de-escalation of antibiotic therapy in patients with ventilator-associated pneumonia.
  
  
  METHODS
  Prospective observational study during a 43-month period.
  
  
  METHODS
  Medical-surgical intensive care unit.
  
  
  METHODS
  One hundred and fifteen patients admitted to the intensive care unit with clinical diagnosis of ventilator-associated pneumonia. All the episodes of ventilator-associated pneumonia received initial broad-spectrum coverage followed by reevaluation according to clinical response and microbiology. Quantitative cultures obtained by bronchoscopic examination or tracheal aspirates were used to modify therapy.
  
  
  METHODS
  : None.
  
  
  RESULTS
  One hundred and twenty-one episodes of ventilator-associated pneumonia were diagnosed. Change of therapy was documented in 56.2%, including de-escalation (the most frequent cause) in 31.4% (increasing to 38% if isolates were sensitive). Overall intensive care unit mortality rate was 32.2%. Inappropriate antibiotic therapy was identified in 9% of cases and was associated with 14.4% excess intensive care unit mortality. Quantitative tracheal aspirates and bronchoscopic samples (58 protected specimen brush and three bronchoalveolar lavage) were associated with 32.7% and 29.5% intensive care unit mortality and 29.3% and 34.4% de-escalation rate. De-escalation was lower (p < .05) in the presence of nonfermenting Gram-negative bacillus (2.7% vs. 49.3%) and in the presence of late-onset pneumonia (12.5% vs. 40.7%). When the pathogen remained unknown, half of the patients died and de-escalation was not performed.
  
  
  CONCLUSIONS
  De-escalation was the most important cause of antibiotic modification, being more feasible in early-onset pneumonia and less frequent in the presence of nonfermenting Gram-negative bacillus. The impact of quantitative tracheal aspirates or bronchoscopic techniques was comparable in terms of mortality.
authors.affiliation: Critical Care Department, Joan XXIII University Hospital, University Rovira i Virgili, Tarragona, Spain.
authors.forename: Jordi
authors.initials: J
authors.lastname: Rello
authors.forename: Loreto
authors.initials: L
authors.lastname: Vidaur
authors.forename: Alberto
authors.initials: A
authors.lastname: Sandiumenge
authors.forename: Alejandro
authors.initials: A
authors.lastname: Rodríguez
authors.forename: Belen
authors.initials: B
authors.lastname: Gualis
authors.forename: Carmen
authors.initials: C
authors.lastname: Boque
authors.forename: Emili
authors.initials: E
authors.lastname: Diaz
mesh_terms: D000465:Algorithms; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001992:Bronchoalveolar Lavage Fluid / Q000382:microbiology; D001999:Bronchoscopy; D015897:Comorbidity; D003422:Critical Care / Q000379:methods / Q000592:standards; D003428:Cross Infection / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology* / Q000401:mortality; D003663:Decision Trees; D036262:Empirical Research; D019317:Evidence-Based Medicine; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D017053:Infection Control; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D018410:Pneumonia, Bacterial / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology* / Q000401:mortality; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000009:adverse effects*; D012307:Risk Factors; D013183:Sputum / Q000382:microbiology; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents