title: Impact of combination therapy and early de-escalation on outcome of ventilator-associated pneumonia caused by Pseudomonas aeruginosa.
abstract: BACKGROUND
  Pseudomonas aeruginosa is a common cause of ventilator-associated pneumonia (VAP). Guidelines recommend dual coverage of P. aeruginosa, but the beneficial effect of combination therapy is controversial. We described antibiotic prescriptions and evaluated the clinical impact of initial combination antibiotic therapy and de-escalation strategy in patients with VAP caused by P. aeruginosa.
  
  
  METHODS
  Between 1994 and 2014, all 100 patients with VAP caused by P. aeruginosa in our intensive care unit (ICU) were included in a retrospective cohort study to evaluate the prognostic impact of initial combination antibiotic therapy.
  
  
  RESULTS
  Eighty-five patients received initial combination antibiotic therapy and 15 monotherapy. Nine patients received inadequate initial antibiotic therapy. De-escalation was performed in 42 patients. Thirty-nine patients died in the ICU. Factors independently associated with death were SAPS II score [SAPS II ≥40 versus <40: hazard ratio (HR) 2.49, 95% confidence interval (CI) 1.08-5.70, p = 0.03] and septic shock (HR = 4.80, 95% CI = 1.90-12.16, p < 0.01) at onset of VAP. Initial combination antibiotic therapy (HR = 1.97, 95% CI = 0.56-6.93, p = 0.29) and early de-escalation (HR = 0.59, 95% CI = 0.27-1.31, p = 0.19) had no impact on mortality. In multivariate analysis, the risk for inappropriate initial antibiotic therapy was higher in cases with multi-drug resistant P. aeruginosa [odd ratio (OR) = 7.11, 95% CI = 1.42-35.51, p = 0.02], but lower in cases with initial combination antibiotic therapy (OR = 0.12, 95% CI = 0.02-0.63, p = 0.01).
  
  
  CONCLUSIONS
  In our cohort, combination therapy increased the likelihood of appropriate therapy but did not seem to impact on mortality.
authors.affiliation: a Service Universitaire des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing , Tourcoing , France.
authors.forename: Laurène
authors.initials: L
authors.lastname: Deconinck
authors.affiliation: a Service Universitaire des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing , Tourcoing , France.
authors.forename: Agnès
authors.initials: A
authors.lastname: Meybeck
authors.affiliation: b Laboratoire de microbiologie, Centre Hospitalier de Tourcoing , Tourcoing , France.
authors.forename: Pierre
authors.initials: P
authors.lastname: Patoz
authors.affiliation: c Service de réanimation, Centre Hospitalier de Tourcoing , Tourcoing , France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Van Grunderbeeck
authors.affiliation: c Service de réanimation, Centre Hospitalier de Tourcoing , Tourcoing , France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Boussekey
authors.affiliation: c Service de réanimation, Centre Hospitalier de Tourcoing , Tourcoing , France.
authors.forename: Arnaud
authors.initials: A
authors.lastname: Chiche
authors.affiliation: c Service de réanimation, Centre Hospitalier de Tourcoing , Tourcoing , France.
authors.forename: Pierre-Yves
authors.initials: PY
authors.lastname: Delannoy
authors.affiliation: c Service de réanimation, Centre Hospitalier de Tourcoing , Tourcoing , France.
authors.forename: Hugues
authors.initials: H
authors.lastname: Georges
authors.affiliation: c Service de réanimation, Centre Hospitalier de Tourcoing , Tourcoing , France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Leroy
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D004359:Drug Therapy, Combination / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D053717:Pneumonia, Ventilator-Associated / Q000188:drug therapy* / Q000401:mortality; D011552:Pseudomonas Infections / Q000188:drug therapy* / Q000401:mortality; D011550:Pseudomonas aeruginosa / Q000302:isolation & purification*; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents
keywords: Pseudomonas aeruginosa; anti-bacterial agents; pneumonia