title: Development of antibiotic treatment algorithms based on local ecology and respiratory surveillance cultures to restrict the use of broad-spectrum antimicrobial drugs in the treatment of hospital-acquired pneumonia in the intensive care unit: a retrospective analysis.
abstract: BACKGROUND
  Timely administration of appropriate antibiotic therapy has been shown to improve outcome in hospital-acquired pneumonia (HAP). Empirical treatment guidelines tailored to local ecology have been advocated in antibiotic stewardship programs. We compared a local ecology based algorithm (LEBA) to a surveillance culture based algorithm (SCBA) in terms of appropriate coverage and spectrum of antimicrobial activity.
  
  
  METHODS
  We retrospectively assessed 2 hypothetical empirical antibiotic treatment algorithms for HAP on an existing high-quality prospectively collected database in a mixed 36-bed tertiary intensive care unit (ICU). Data on consecutive episodes of microbiologically confirmed HAP were collected over a period of 40 months and divided in a derivation (1 July 2009 to 31 October 2010) and validation (1 November 2010 until 31 October 2012) cohort. On the derivation cohort we constructed a LEBA, based on overall observed bacterial resistance patterns, and a SCBA, which targeted therapy to surveillance culture (SC) in the individual patient. Therapy was directed against pathogens found in respiratory SC collected two to five days before HAP, and in the absence of these, presence or absence of multi-drug resistant (MDR) pathogens in other SC dictated broad-spectrum, respectively narrow spectrum antibiotic therapy. Subsequently, LEBA and SCBA were retrospectively reviewed and compared with actually prescribed antibiotics in the validation cohort.
  
  
  RESULTS
  The first 100 HAP episodes made up the derivation cohort and the subsequent 113 HAP episodes the validation cohort. Appropriate antibiotic coverage rates by applying LEBA and SCBA were 88.5% and 87.6%, respectively, and did not differ significantly with respect to appropriateness of the actually prescribed initial therapy (84.1%). SCBA proposed more narrow spectrum therapy as compared to LEBA and the actually prescribed antimicrobials (P <0.001). SCBA recommended significantly less combination therapy and carbapenems compared to LEBA (P <0.001). SCBA targeted antibiotics to recent respiratory SC in 38.1% (43 out of 113 episodes) of HAP; in these cases adequacy was 93% (40 out of 43).
  
  
  CONCLUSIONS
  Rates of appropriate antimicrobial coverage were identical in LEBA and SCBA. However, in this setting of moderate MDR prevalence, the use of SCBA would result in a significant reduction of the use of broad-spectrum drugs and may be a preferential strategy when implementing antibiotic stewardship programs.
authors.forename: Liesbet
authors.initials: L
authors.lastname: De Bus
authors.forename: Lies
authors.initials: L
authors.lastname: Saerens
authors.forename: Bram
authors.initials: B
authors.lastname: Gadeyne
authors.forename: Jerina
authors.initials: J
authors.lastname: Boelens
authors.forename: Geert
authors.initials: G
authors.lastname: Claeys
authors.forename: Jan J
authors.initials: JJ
authors.lastname: De Waele
authors.forename: Dominique D
authors.initials: DD
authors.lastname: Benoit
authors.forename: Johan
authors.initials: J
authors.lastname: Decruyenaere
authors.forename: Pieter O
authors.initials: PO
authors.lastname: Depuydt
mesh_terms: D000368:Aged; D000465:Algorithms; D000890:Anti-Infective Agents / Q000494:pharmacology / Q000627:therapeutic use*; D015331:Cohort Studies; D003428:Cross Infection / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D024901:Drug Resistance, Multiple, Bacterial / Q000187:drug effects; D055669:Ecological and Environmental Phenomena; D062665:Epidemiological Monitoring; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000592:standards; D008297:Male; D008875:Middle Aged; D018410:Pneumonia, Bacterial / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D053717:Pneumonia, Ventilator-Associated / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D012121:Respiration, Artificial / Q000009:adverse effects; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D000890:Anti-Infective Agents