title: Aggressive versus conservative antibiotic use to prevent and treat ventilator-associated pneumonia in patients with severe traumatic brain injury: comparison of two case series.
abstract: BACKGROUND
  In patients with traumatic brain injury (TBI), ventilator-associated pneumonia (VAP) is considered a dangerous complication, prompting early aggressive antibiotic treatment and prophylaxis. While this approach increases the selection of multidrug-resistant bacteria (MDR), its clinical benefit has not been demonstrated.
  
  
  METHODS
  One-year incidence of VAP in severe TBI patients (ICU stay >48 hours, with either Glasgow Coma Scale ≤8 or receiving intracranial pressure monitoring, or having undergone emergency surgery) and the prevalence of MDR among those who eventually developed it, were compared in two Italian intensive care units (ICUs) adopting different antibiotic approaches. Antibiotic use was guideline-driven and aggressive in the Pisa-based unit (165 eligible patients), and very conservative and coupled with non-pharmacological prevention measures in Cesena (262 patients). Data were also compared with those of 208 Italian ICUs participating in the same infection surveillance program.
  
  
  RESULTS
  Patient case mix and general care were similar in the two units. Overall antibiotic pressure was higher in Pisa (58.9% vs. 26.1% of beds occupied by patients receiving antibiotics, P<0.0001), as was antibiotic prophylaxis in eligible patients (87.3% vs. 7.6%, P<0.0001; Italian ICUs, 69.2%) and empirical therapy in those who developed VAP (60.8% vs. 25.2%, P<0.0001; Italian ICUs, 51.6%). The incidence rate of VAP did not significantly differ (39.8 per 1000 days of mechanical ventilation in Pisa, 49.3 in Cesena, P=0.16), although it occurred earlier in Cesena (23.0% early VAP in Pisa vs. 61.2% in Cesena, P<0.0001). Mortality was higher in Pisa but Cesena transferred more patients to other hospitals, precluding comparison of the two rates. The prevalence of MDR was higher in Pisa (38.2% vs. 9.9%, P<0.0001; Italian ICUs, 30.2%).
  
  
  CONCLUSIONS
  Although not conclusive, these results call into question the prevalent aggressive use of antibiotics in TBI patients and urge the scientific community to produce better evidence for clinical recommendations.
authors.affiliation: Unit of Neuororesuscitation, Department of Anesthesia, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
authors.forename: Arturo
authors.initials: A
authors.lastname: Chieregato
authors.affiliation: Unit of Anesthesia and Resuscitation, AOU Pisa, Pisa, Italy - pmalacarne@hotmail.com.
authors.forename: Paolo
authors.initials: P
authors.lastname: Malacarne
authors.affiliation: Unit of Anesthesia and Resuscitation, AUSL Romagna, Cesena, Forlì Cesena, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Cocciolo
authors.affiliation: Unit of Anesthesia and Resuscitation, AUSL Romagna, Cesena, Forlì Cesena, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Ravaldini
authors.affiliation: Unit of Anesthesia and Resuscitation, AUSL Romagna, Cesena, Forlì Cesena, Italy.
authors.forename: Emanuele
authors.initials: E
authors.lastname: Russo
authors.affiliation: Unit of Neuroanesthesia and Intensive Therapy, AOU Careggi, Florence, Italy.
authors.forename: Bruno
authors.initials: B
authors.lastname: Viaggi
authors.affiliation: GiViTI Coordinating Center, IRCCS-Istituto di Ricerche Farmacologiche &quot;Mario Negri&quot;, Centro di Ricerche Cliniche per le Malattie Rare Aldo e Cele Daccò, Ranica, Bergamo, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Giardino
authors.affiliation: GiViTI Coordinating Center, IRCCS-Istituto di Ricerche Farmacologiche &quot;Mario Negri&quot;, Centro di Ricerche Cliniche per le Malattie Rare Aldo e Cele Daccò, Ranica, Bergamo, Italy.
authors.forename: Carlotta
authors.initials: C
authors.lastname: Rossi
authors.affiliation: Lucca Provincial Hospital, ASL Lucca, Lucca, Italy.
authors.forename: Bruno
authors.initials: B
authors.lastname: Simini
authors.affiliation: GiViTI Coordinating Center, IRCCS-Istituto di Ricerche Farmacologiche &quot;Mario Negri&quot;, Centro di Ricerche Cliniche per le Malattie Rare Aldo e Cele Daccò, Ranica, Bergamo, Italy.
authors.forename: Guido
authors.initials: G
authors.lastname: Bertolini
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D000070642:Brain Injuries, Traumatic / Q000150:complications; D011307:Drug Prescriptions / Q000706:statistics & numerical data; D024901:Drug Resistance, Multiple, Bacterial; D005260:Female; D006801:Humans; D015994:Incidence; D015601:Injury Severity Score; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D053717:Pneumonia, Ventilator-Associated / Q000188:drug therapy* / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*
chemical_list: D000900:Anti-Bacterial Agents