Burke A. Cunha, MD, MACP

In intubated adult ICU patients, the diagnosis of MRSA ventilator-associated pneumonia, or VAP, is based on epidemiologic/microbiologic criteria. The characteristic clinical features of MRSA pneumonia are well-known from decades of clinical experience with MRSA community-acquired pneumonia in patients with influenza. This is the gold standard of diagnosing MRSA pneumonia.

The latest recommendations from the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America on antimicrobial stewardship programs, or ASPs, are a plea for hospitals to support their ASPs, and their recommendations consist of more than a dozen suggestions. Clearly, all hospitals and practitioners support optimal antibiotic use. The problem is to recognize that each hospital is different in terms of infectious disease and infection control expertise, antibiotic use habits, antibiotic resistance patterns and Clostridium difficile incidence. Components of some ASPs may have little or no relevance for hospitals of different sizes, demographics and geographic location. The great value of the prospective audit is to tailor ASPs to the needs of the hospital. “One size does not fit all,” and most importantly, “the devil is in the details.” There are some reasonable ASP objectives, and there are extremely difficult ASP problems that often defy the best-intended efforts to improve or solve.

Traditionally, initial antimicrobial therapy for immediately life-threatening infections was administered intravenously. IV therapy has a rapid onset and delivers therapeutic blood/tissue levels in less than half an hour. Early in the antibiotic era, since the number of oral antibiotics available was limited and pharmacokinetic principles were just being applied to oral antibiotics, the notion that IV therapy was “more effective” than oral therapy became established. IV antibiotic therapy was preferred to oral therapy not only for critically ill patients but became the standard approach even for nonacute infections.

An abstract, titled “Epidemiology of Q fever in Thailand,” was presented at the American Society of Tropical Medicine and Hygiene meeting in November by Padungtod and colleagues from the National Health Authorities in Bangkok and the CDC in the United States.