title: Effect of antibiotic diversity on ventilator-associated pneumonia caused by ESKAPE Organisms.
abstract: BACKGROUND
  The aim of this study was to test in the clinic whether antimicrobial diversity affects resistance of Enterococcus faecium, Staphylococcus aureus, Klebsiella species, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species (ESKAPE) pathogens in ventilator-associated pneumonia (VAP).
  
  
  METHODS
  Three different strategies of empirical antimicrobial prescription for VAP were consecutively implemented in an ICU: patient specific (10 months); scheduling, including sequential quarterly prioritization (12 months) and restriction (12 months) of antimicrobials; and mixing (10 months). Periods were compared, measuring the antimicrobial heterogeneity index (AHI). Incidence and resistance patterns of VAP caused by ESKAPE were compared.
  
  
  RESULTS
  Overall, 127 microbiologic VAP episodes were documented. ESKAPE VAP increased significantly during scheduling (AHI, 0.65) compared with patient-specific (AHI, 0.88) and mixing (AHI, 0.87) periods (relative risk, 2.67 and 3.84, respectively). This finding was associated with a significant (P < .05) increase of carbapenem-resistant A baumannii during the scheduling period (15.0%) compared with the patient-specific (2.4%) and mixing (0%) periods. ICU mortality of resistant patients with ESKAPE VAP was doubled that of patients without ESKAPE VAP (relative risk, 2.25; 95% CI, 1.67-9.48). Thirty-day mechanical ventilation-free days was significantly increased (5 days) in patients with resistant ESKAPE VAP.
  
  
  CONCLUSIONS
  Antibiotic strategies promoting diversity may prevent the emergence of resistance of ESKAPE organisms, improving use of health-care resources.
authors.affiliation: Critical Care Department, CIBERES, Joan XXIII University Hospital, Tarragona, Spain. Electronic address: asandiumenge@yahoo.com.
authors.forename: Alberto
authors.initials: A
authors.lastname: Sandiumenge
authors.affiliation: Critical Care Department, Hospital de Clinicas, Porto Alegre, Brazil.
authors.forename: Thiago
authors.initials: T
authors.lastname: Lisboa
authors.affiliation: IISPV, Microbiology Department, CIBERES, Joan XXIII University Hospital, Tarragona, Spain.
authors.forename: Frederic
authors.initials: F
authors.lastname: Gomez
authors.affiliation: Epidemiology Department, CIBERES, Joan XXIII University Hospital, Tarragona, Spain.
authors.forename: Pilar
authors.initials: P
authors.lastname: Hernandez
authors.affiliation: Pharmacology Department, CIBERES, Joan XXIII University Hospital, Tarragona, Spain.
authors.forename: Laura
authors.initials: L
authors.lastname: Canadell
authors.affiliation: Critical Care Department, Vall d'Hebron University Hospital, Institut de Recerca Vall d'Hebron, CIBERES, Universitat Autonoma de Barcelona, Spain.
authors.forename: Jordi
authors.initials: J
authors.lastname: Rello
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D004352:Drug Resistance, Microbial; D005260:Female; D016905:Gram-Negative Bacterial Infections / Q000517:prevention & control*; D006801:Humans; D017053:Infection Control / Q000379:methods*; D008297:Male; D008826:Microbial Sensitivity Tests; D018410:Pneumonia, Bacterial / Q000517:prevention & control; D053717:Pneumonia, Ventilator-Associated / Q000382:microbiology* / Q000517:prevention & control*; D011446:Prospective Studies
chemical_list: D000900:Anti-Bacterial Agents