Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit
- 428 Downloads
To assess the frequency of and the reasons for changing empiric antibiotics during the treatment of pnnumonia acquired in the intensive care unit (ICU).
A prospective multicenter study of 1 year's duration.
Medical and surgical ICUs in 30 hospitals all over Spain.
Of a total of 16872 patients initially enrolled into the study, 530 patients developed 565 episodes of pneumonia after admission to the ICU.
Empiric antibiotics were administered in 490 (86.7%) of the 565 episodes of pneumonia. The antimicrobials most frequently used were amikacin in 120 case, tobramycin in 110, ceftazidime in 96, and cefotaxime in 96. Monotherapy was indicated in 135 (27.6%) of the 490 episodes, a combination of two antibiotics in 306 episodes (62.4%), and a combination of three antibiotics in 49 episodes (10%). The empiric antibiotic treatment was modified in 214 (43.7%) cases because of isolation of a microorganism not covered by treatment in 133 (62.1%) cases, lack of clinical response in 77 (36%), and development of resistance in 14 (6.6%). Individual factors associated with modification of empiric treatment identified in the multivariate analysis were microorganism not covered (relative risk (RR)) 22.02; 95% confidence interval (CI) 11.54 to 42.60;p<0.0001), administration of more than one antimicrobial (RR 1.29; 95% CI 1.02 to 1.65;p=0.0018) attributable mortability was 16.2%.
Unable to display preview. Download preview PDF.
- 1.Pennington JE (1990) Nosocomial respiratory infection. In: Mandell GL, Douglas RG, Bennet JE (eds) Principles and practice of infectious diseases. Churchill Livingstone, New York, pp 2199–2204Google Scholar
- 2.Unterl KE, Lenhart FP, Forst H, Peter K (1992) Systemic antibiotic treatment of noscomial pneumonia. Intensive Care Med 18:28–34Google Scholar
- 3.Salata RA, Lederman MM, Shlaes DM, Jacobs MR, Eckstein E, Tweardy D, et al (1987) Diagnosis of nosocomial pneumonia in intubated intensive care unit patients. Am Rev Respir Dis 135: 426–432Google Scholar
- 4.Chastre J, Fagon JY, Domart Y, Gibert C (1989) Diagnosis of noscomial pneumonia in intensive care unit patients. Eur J Clin Microbiol Infect Dis 8:35–39Google Scholar
- 5.Craig CP, Connelly S (1984) Effect of intensive care unit nosocomial pneumonia on duration of stay and mortality. Infect Contro 12:233–238Google Scholar
- 6.Fagon JY, Chastre J, Hance AJ, Montravers PH, Novara A, Gibert C (1983) Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J Med 94:281–288Google Scholar
- 7.Alvarez F (1991) Tratamiento empirico de las neumonías nosocomiales en pacients ventilados. Rev Exp Quimioterap 4:37–43Google Scholar
- 8.Alvarez F (1993) Neumonía en el paciente intubado. Aspectos terapéuticos. In: Picazo JJ, Romero J (eds) Infecciones en unidades de cuidados intensivos. Doyma, Barcelona, pp. 49–62Google Scholar
- 9.LaForce FM (1989) Systemic antimicrobial therapy of nosomial pneumonia: monotherapy versus combination therapy. Eur J Clin Microbiol Infect Dis 8:61–68Google Scholar
- 10.Young LS (1984) Treatment of respiratory infections in the patients at risk. Am J Med 76 [Suppl SA]:61–68Google Scholar
- 11.Fink MP, Snydman DR, Nierderman MS, Leeper KV, Johnson RH, Heard SO, et al. (1994) Treatment of severe pneumonia in hospitalized patients: results of a multicenter, randomized, double-blind trial comparing intravenous ciprofloxacin with imipenemcilastatin. Antimicrob Agents Chemother 38:547–557Google Scholar
- 12.Marco V, Gobernado M, Santos M, Rabinad E, Spanish Study Group (1989) Comparative study of aztreonam in gram-negative pneumonia versus a therapeutic regimen that includes an aminoglycoside. Chemotherapy 35 [Suppl 1]:81–88Google Scholar
- 13.Acar JF (1985) Therapy for lower respiratory tract infections with imipenem-cilastatin; a review of worldwide experience. Rev Infect Dis 7 [Suppl 3]:513–517Google Scholar
- 14.Haverkorn MJ (1988) Ciprofloxacin therapy of respiratory tract infection withPseddomonas aeruginosa. Eur J Clin Microbiol Infect Dis 7:661–664Google Scholar
- 15.Graner JS, Jarvis WR, Emori TG, Moran TC, Hughes JM (1988) CDC definitions for nosocomial infections. Am J Infect Control 16:128–140Google Scholar
- 16.McCabe WR, Jackson GG (1962) Gram-negative bacteriemia. Etioilogy and ecology. Arch Intern Med 110: 847–855Google Scholar
- 17.Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Laurence DE (1981) APACHE-Acute Physiuology and Chronic health Evaluation: a physiologically based classification system. Crit Care Med 9:591–597Google Scholar
- 18.Hosmer DW, Lemeshow I (1989) Applied logistic regression. Wiley, New yorkGoogle Scholar
- 19.Chevret S, Hemmer M, Carlet J, Langer M, European Cooperative Group of Nosocomial Pneumonia (1993) Incidence and risk factors of pneumonia acquired in intensive care units. Results from a multicenter prospective study on 996 patients. Intensive Care Med 19: 256–264Google Scholar
- 20.Joshi N, Localio AR, Hamory BH (1992) A predictive risk index for nosocomial pneumonia in the intesive care unit. Am J Med 93:135–142Google Scholar
- 21.Wenzel RP, Thompson RL, Landry SM, Russell BS, Miller PJ, Ponce de Leon S, Miller GB Jr (1983) Hospital-acquired infections in intensive care unit patients: an overview with emphathis with emphasis on eipidemics. Infect Control 5:371–375Google Scholar
- 22.Andrews CP, Coalson JJ, Smith JD, Johanson WG (1981) Diagnosis of nosocomial bacterial pneumonia in acute diffuse lung injury. Chest 80: 254–258Google Scholar
- 23.Fagon JY, Chastre J, Hance AJ, Domart y Trouillet JL, Gibert C (1993). Evaluation of clinical judment in the identification and treatment of nosocomial pneumonia in ventilated patients. Chest 103:543–553Google Scholar
- 24.Shentag JJ, Vari AJ, Winslande NE, et al. (1985) Treatment with azteonam or tobramycin in intial care patients with nosocomial gram-negative rod pneumonia. Am J Med 78 [Suppl 2A]:34–41Google Scholar
- 25.Flint LM, Gott J, Short L, Richardson JD, Polk HL (1985) Serum level monitoring aminoglycoside antibiotics limitations in intensive care unit-related bacterial pneumonia. Arch Surg 120: 99–103Google Scholar
- 26.Pennington JE (1981) Pencetration of antibiotics into respiratory secretions. Rev Infect Dis 3:67–73Google Scholar
- 27.Bodem CR, Lampton LM, Miller DP, et al (1983) Endobronchial pH: relevance to aminoglycoside activity in gramnegative bacillary pneumonia. Am Rev Respir Dis 127:39–41Google Scholar
- 28.Moore RD, Smith CR, Lietman PS (1984) Association of aminoglycoside plasma levels with therapeuti outcome in gram-negative pneumonia. Am J Med 77:657–662Google Scholar
- 29.Martínez A, Alvarez B, Melgarejo A, Palacios F, Calvo R, Grupo de estudio de neumonia adquirida en UCI (1990) Etiología de la neumonia nosocomial en cuidados intensivos. Factores predisponentes Med Intensiva 14:423–426Google Scholar
- 30.Rello J, Ausina V, Ricart M, Castella J, Prats G (1993) Impact of previous antimicrobial therapy on the etiology and outcome of ventilator-associated pneumonia. Chest 104:1230–1235Google Scholar
- 31.Nierderman MS, Torres A, Summer W (1994) Invasive diagnostic testing is not needed routinely to manage suspected ventilator-associated pneumonia. Am J Respir Crit Cae Med 150: 565–569Google Scholar
- 32.Chastre J, Fagon JY (1994) Invasive diagnostic testing should be rountinely used to manage ventilated patients with suspected pneumonia. Am J Respir Crit Care Med 150:570–574Google Scholar