PMID- 23268613
OWN - NLM
STAT- MEDLINE
DCOM- 20130529
LR  - 20121227
IS  - 1557-8674 (Electronic)
IS  - 1096-2964 (Linking)
VI  - 13
IP  - 6
DP  - 2012 Dec
TI  - Locally derived versus guideline-based approach to treatment of hospital-acquired 
      pneumonia in the trauma intensive care unit.
PG  - 352-9
LID - 10.1089/sur.2011.056 [doi]
AB  - BACKGROUND: Appropriate initial antibiotic therapy for presumed pneumonia in 
      critically ill patients decreases the mortality rate. To achieve this goal, 
      treatment guidelines developed by groups such as the American Thoracic Society 
      (ATS) have been stressed. However, often overlooked is the importance of 
      incorporating local microbiologic data into an empiric algorithm. Our hypothesis 
      was that an empiric algorithm supported by our locally-driven analysis would 
      predict more accurate coverage than one defined strictly by an unmodified 
      guideline-driven approach. METHODS: Retrospective review of all first 
      hospital-acquired (HAP) and ventilator-associated pneumonia (VAP) pathogens in 
      consecutive trauma intensive care unit (TICU) patients over 18 months. 
      Microbiologic data were analyzed to update our TICU-specific empiric algorithm. 
      The ATS guidelines define patients at risk for multidrug-resistant (MDR) 
      organisms on the basis of standardized criteria and time since admission (early 
      <5 days; late >/=5 days). RESULTS: A total of 164 pathogens caused 117 pneumonias. 
      For early coverage, ATS guidelines stress identification of MDR risks; these 
      criteria failed to identify 8 of 13 (62%) early MDR pneumonias. For early HAP/VAP 
      with no MDR risks, the ATS guidelines recommend monotherapy; susceptibility 
      differed (49% to ciprofloxacin, 68% to ampicillin-sulbactam, 83% to ceftriaxone). 
      A total of 15% of early pathogens were MDR gram-positive, so addition of 
      vancomycin resulted in adequate predicted coverage of 100%, 79%, and 95% for 
      ciprofloxacin, ampicillin-sulbactam, and ceftriaxone, respectively. For late 
      HAP/VAP, ATS recommends regimens based on broad-spectrum drugs. Vancomycin with 
      ciprofloxacin, cefepime, or piperacillin-tazobactam had predicted coverage of 
      95%, 94%, and 93%, respectively. CONCLUSIONS: The empiric algorithm derived from 
      analysis of local microbiologic data predicted significantly better coverage than 
      one defined by an unmodified guideline-driven approach for early HAP/VAP. Our 
      locally-derived TICU algorithm of ceftriaxone+vancomycin for early pneumonia and 
      piperacillin-tazobactam+vancomycin for late pneumonia optimizes the adequacy of 
      initial therapy. Understanding local patterns of pneumonia ensures the creation 
      and maintenance of empiric algorithms that achieve the best clinical outcomes.
FAU - Becher, Robert D
AU  - Becher RD
AD  - Acute Care Surgery Service, Department of General Surgery, Wake Forest University 
      School of Medicine, Winston-Salem, North Carolina 27157, USA. 
      rbecher@wakehealth.edu
FAU - Hoth, J Jason
AU  - Hoth JJ
FAU - Rebo, Jerry J
AU  - Rebo JJ
FAU - Kendall, Jennifer L
AU  - Kendall JL
FAU - Miller, Preston R
AU  - Miller PR
LA  - eng
PT  - Journal Article
PL  - United States
TA  - Surg Infect (Larchmt)
JT  - Surgical infections
JID - 9815642
RN  - 0 (Anti-Bacterial Agents)
SB  - IM
MH  - Algorithms
MH  - Anti-Bacterial Agents/pharmacology/therapeutic use
MH  - Bacteria/drug effects/isolation & purification
MH  - Cross Infection/*drug therapy/microbiology
MH  - Decision Support Systems, Clinical
MH  - Drug Resistance, Multiple, Bacterial
MH  - Guideline Adherence
MH  - Humans
MH  - *Intensive Care Units
MH  - Length of Stay
MH  - Microbial Sensitivity Tests
MH  - Pneumonia, Bacterial/*drug therapy/microbiology
MH  - Pneumonia, Ventilator-Associated/drug therapy/microbiology
MH  - Practice Guidelines as Topic
MH  - Retrospective Studies
MH  - Risk Factors
MH  - Trauma Centers
EDAT- 2012/12/28 06:00
MHDA- 2013/05/31 06:00
CRDT- 2012/12/28 06:00
PHST- 2012/12/28 06:00 [entrez]
PHST- 2012/12/28 06:00 [pubmed]
PHST- 2013/05/31 06:00 [medline]
AID - 10.1089/sur.2011.056 [doi]
PST - ppublish
SO  - Surg Infect (Larchmt). 2012 Dec;13(6):352-9. doi: 10.1089/sur.2011.056.