title: Improving Antibiotic De-Escalation in Suspected Ventilator-Associated Pneumonia: An Observational Study With a Pharmacist-Driven Intervention.
abstract: BACKGROUND
  Recommendations for treatment of ventilator-associated pneumonia (VAP) emphasize early empiric broad-spectrum antibiotics. However, appropriate antibiotic de-escalation is also critical for optimal patient care.
  
  
  METHODS
  We examined how often intensivists in our institution appropriately de-escalated antibiotics in cases of suspected VAP, and whether decision support by intensive care unit pharmacists could improve rates of antibiotic targeting and early antibiotic discontinuation in low-risk patients.
  
  
  RESULTS
  A total of 92 (observation phase = 50; intervention phase = 42) patients with suspected VAP were identified. During the observation phase, 39 cases yielded positive sputum cultures, but in only 23 (59%) were antibiotics targeted to culture results. This rate improved during the intervention phase when 29 (91%) of 32 cases with positive cultures were targeted (P value .003). There were 48 cases in which the risk of pneumonia was considered low. Of the 26 low-risk cases in the observation phase, 5 (19%) had antibiotics discontinued early versus 5 (23%) of the 22 cases in the intervention phase.
  
  
  CONCLUSIONS
  Decision support by clinical pharmacists significantly improved rates of appropriate antibiotic targeting in cases of culture-positive suspected VAP but did not have a significant effect on early antibiotic discontinuation in patients at low risk of true pneumonia.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University david.oxman@jefferson.edu.
authors.forename: David A
authors.initials: DA
authors.lastname: Oxman
authors.affiliation: Department of Pharmacy, Brigham and Women's Hospital.
authors.forename: Christopher D
authors.initials: CD
authors.lastname: Adams
authors.affiliation: Division of Surgical Intensive Care, Brigham and Women's Hospital Department of Anesthesia, Brigham and Women's Hospital.
authors.forename: Gretchen
authors.initials: G
authors.lastname: Deluke
authors.affiliation: Division of Surgical Intensive Care, Brigham and Women's Hospital Department of Anesthesia, Brigham and Women's Hospital.
authors.forename: Lauren
authors.initials: L
authors.lastname: Philbrook
authors.affiliation: Division of Surgical Intensive Care, Brigham and Women's Hospital Department of Anesthesia, Brigham and Women's Hospital.
authors.forename: Peter
authors.initials: P
authors.lastname: Ireland
authors.affiliation: Department of Anesthesia, Brigham and Women's Hospital.
authors.forename: Aya
authors.initials: A
authors.lastname: Mitani
authors.affiliation: Division of Surgical Intensive Care, Brigham and Women's Hospital Department of Anesthesia, Brigham and Women's Hospital.
authors.forename: Christia
authors.initials: C
authors.lastname: Panizales
authors.affiliation: Division of Surgical Intensive Care, Brigham and Women's Hospital Department of Anesthesia, Brigham and Women's Hospital.
authors.forename: Gyorgy
authors.initials: G
authors.lastname: Frendl
authors.affiliation: Department of Surgery, Temple University Hospital.
authors.forename: Selwyn O
authors.initials: SO
authors.lastname: Rogers
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D003428:Cross Infection / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000639:trends; D008297:Male; D008875:Middle Aged; D010595:Pharmacists; D053717:Pneumonia, Ventilator-Associated / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D024382:Professional Role; D011446:Prospective Studies; D028761:Withholding Treatment / Q000639:trends*; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents
keywords: antibiotic de-escalation; critical care; pneumonia; ventilator-associated pneumonia