title: Ventilator-associated pneumonia: breaking the vicious circle of antibiotic overuse.
abstract: OBJECTIVE
  To assess the rate of appropriateness of empirical antimicrobial therapy for ventilator-associated pneumonia, to evaluate de-escalation in patients with ventilator-associated pneumonia treated according to local pathway, and to identify the bacteria responsible for recurrence of ventilator-associated pneumonia.
  
  
  METHODS
  Prospective observational study during a 36-month period.
  
  
  METHODS
  Medical-surgical intensive care unit of a university hospital.
  
  
  METHODS
  One hundred and fifteen patients hospitalized in an intensive care unit developing ventilator-associated pneumonia with positive cultures. The patients with ventilator-associated pneumonia were treated with limited-spectrum antibiotics (i.e., without activity against Pseudomonas aeruginosa) if they had no prior hospitalization (within 21 days) or prior administration of antibiotics (within 10 days). Quantitative cultures obtained by bronchoscopy or tracheal aspiration were used to reassess empirical therapy.
  
  
  METHODS
  None.
  
  
  RESULTS
  A limited-spectrum therapy was used in 79 patients (69%). Empirical antimicrobial therapy was appropriate in 100 patients (85%). The mortality rate was significantly higher in the patients in whom empirical therapy was inappropriate than in those in whom treatment was appropriate (47 vs. 20%, p=.04). De-escalation was done in respectively 26% and 72% of patients with early- and late-onset ventilator-associated pneumonia, whereas treatment was escalated in 27 patients (23%). Ventilator-associated pneumonia episodes were recurrent in 22 cases, including eight episodes due to high-risk bacteria.
  
  
  CONCLUSIONS
  A rational empirical antimicrobial therapy for ventilator-associated pneumonia using limited-spectrum antibiotics is possible if local ecology and patient medical history and clinical status are considered. In addition, de-escalation is feasible in 42% of patients. This integrative approach may reduce the emergence of resistant bacteria, which in turns reduces the need for broad-spectrum antibiotics, breaking the vicious circle of antibiotic overuse.
authors.affiliation: Intensive Care Unit, Département d'Anesthésie et de Réanimation, Assistance Publique-Hôpitaux de Marseille, Public Hospitals of Marseille, Marseille Medicine University, France.
authors.forename: Marc
authors.initials: M
authors.lastname: Leone
authors.forename: Frédéric
authors.initials: F
authors.lastname: Garcin
authors.forename: Julien
authors.initials: J
authors.lastname: Bouvenot
authors.forename: Ioanna
authors.initials: I
authors.lastname: Boyadjev
authors.forename: Pierre
authors.initials: P
authors.lastname: Visintini
authors.forename: Jacques
authors.initials: J
authors.lastname: Albanèse
authors.forename: Claude
authors.initials: C
authors.lastname: Martin
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001419:Bacteria / Q000302:isolation & purification; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D053717:Pneumonia, Ventilator-Associated / Q000188:drug therapy* / Q000382:microbiology*; D011446:Prospective Studies
chemical_list: D000900:Anti-Bacterial Agents