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Original Research: CRITICAL CARE |

Effect of Antibiotic Diversity on Ventilator-Associated Pneumonia Caused by ESKAPE OrganismsVentilator-Associated Pneumonia and Pathogens

Alberto Sandiumenge, MD, PhD; Thiago Lisboa, MD; Frederic Gomez, MD; Pilar Hernandez; Laura Canadell, PharmD; Jordi Rello, MD, PhD
Author and Funding Information

From the Critical Care Department (Dr Sandiumenge), Epidemiology Department (Ms Hernandez), and Pharmacology Department (Dr Canadell), IISPV, and Microbiology Department (Dr Gomez), CIBERES, Joan XXIII University Hospital, Tarragona, Spain; Critical Care Department (Dr Lisboa), Hospital de Clinicas, Porto Alegre, Brazil; and Critical Care Department (Dr Rello), Vall d’Hebron University Hospital, Institut de Recerca Vall d’Hebron, CIBERES, Universitat Autonoma de Barcelona, Spain.

Correspondence to: Alberto Sandiumenge, MD, PhD, Critical Care Department, Joan XXIII University Hospital, Carrer Dr Mallafre Guasch 4, 43007 Tarragona, Spain; e-mail: asandiumenge@yahoo.com


Funding/Support: This work was supported by Centro de Investigación Biomedica en Red Enfermedades Respiratorias (CIBERES) (06/06/36).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;140(3):643-651. doi:10.1378/chest.11-0462
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Background:  The aim of this study was to test in the clinic whether antimicrobial diversity affects resistance of Enterococcus faecium, Staphylococcus aureus, Klebsiella species, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species (ESKAPE) pathogens in ventilator-associated pneumonia (VAP).

Methods:  Three different strategies of empirical antimicrobial prescription for VAP were consecutively implemented in an ICU: patient specific (10 months); scheduling, including sequential quarterly prioritization (12 months) and restriction (12 months) of antimicrobials; and mixing (10 months). Periods were compared, measuring the antimicrobial heterogeneity index (AHI). Incidence and resistance patterns of VAP caused by ESKAPE were compared.

Results:  Overall, 127 microbiologic VAP episodes were documented. ESKAPE VAP increased significantly during scheduling (AHI, 0.65) compared with patient-specific (AHI, 0.88) and mixing (AHI, 0.87) periods (relative risk, 2.67 and 3.84, respectively). This finding was associated with a significant (P < .05) increase of carbapenem-resistant A baumannii during the scheduling period (15.0%) compared with the patient-specific (2.4%) and mixing (0%) periods. ICU mortality of resistant patients with ESKAPE VAP was doubled that of patients without ESKAPE VAP (relative risk, 2.25; 95% CI, 1.67-9.48). Thirty-day mechanical ventilation-free days was significantly increased (5 days) in patients with resistant ESKAPE VAP.

Conclusions:  Antibiotic strategies promoting diversity may prevent the emergence of resistance of ESKAPE organisms, improving use of health-care resources.

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