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Outcomes similar among certain patients with suspected VAP receiving shorter vs. longer therapy
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Patients with suspected ventilator-associated pneumonia but minimal and stable ventilator settings who received antibiotic therapy for 3 days or less had outcomes similar to those who received treatment for more than 3 days, according to data published in Clinical Infectious Diseases.
Michael Klompas, MD, MPH, of the department of population medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute, and the department of medicine at Brigham and Women’s Hospital in Boston, and colleagues reported that 50% to 70% of antibiotics prescribed in ICUs are administered for suspected respiratory infections — a “substantial fraction” of which may be unnecessary. They noted that inappropriate antibiotic use for possible ventilator-associated pneumonia (VAP) is to some extent due to guidelines that encourage early and aggressive prescribing, and difficultly in diagnosing VAP, which is associated with nonspecific clinical signs such as fever, leukocytosis, increased secretions and radiographic infiltrates.
“It is unrealistic to expect clinicians to withhold antibiotics when they first suspect VAP given the difficulty making a certain diagnosis and ample data associating delayed treatment with increased mortality,” they wrote. “Focusing on early discontinuation instead, once clinicians have had a chance to observe patients’ clinical trajectories, may be more promising.”
Klompas and colleagues conducted a retrospective analysis at Brigham and Women’s Hospital to determine whether patients with suspected VAP but minimal and stable ventilator settings (defined as daily minimum positive end-expiratory pressure ≤5 cm H2O and daily minimum fraction of inspired oxygen of ≤40%) may be eligible for early discontinuation. They compared the outcomes of 259 adults who were prescribed antibiotics for up to 3 days with the outcomes of 1,031 adults who were prescribed antibiotics for more than 3 days.
The primary analysis revealed that there were no significant differences in the time to extubation (HR = 1.16; 95% CI, 0.98-1.36), ventilator death (HR = 0.82; 95% CI, 0.55-1.22), hospital discharge (HR = 1.07; 95% CI, 0.91-1.26), or hospital death (HR = 0.99; 95% CI, 0.75-1.31) between the two groups. In all cases, the estimates for these outcomes favored patients who received shorter treatment courses. Sensitivity analyses restricting the cohort to propensity-matched pairs, patients with diagnosis codes for VAP and those with potentially pathogenic organisms yielded similar results.
“These observations suggest the possibility that patients with suspected VAP but minimal and stable ventilator settings can be adequately managed with very short courses of antibiotics,” the researchers concluded. “If these findings are confirmed, assessing ventilator settings may prove to be a simple and objective strategy to identify potential candidates for early antibiotic discontinuation.” – by Stephanie Viguers
Disclosure: The researchers report no relevant financial disclosures.
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