0
Correspondence |

Antibiotic Prophylaxis for Ventilator-Associated PneumoniaAntibiotic Prophylaxis for Pneumonia: More Is Less or Less Is More? FREE TO VIEW

Tom Hellyer, MD; Andrew Conway Morris, MD, PhD; A. John Simpson, MD, PhD
Author and Funding Information

From the Institute of Cellular Medicine (Dr Hellyer and Prof Simpson), Newcastle University; and University of Edinburgh/MRC Centre for Inflammation Research (Dr Conway Morris).

Correspondence to: Tom Hellyer, MD, Fourth Floor, William Leech Building, Medical School, Newcastle University, Framlington Pl, Newcastle upon Tyne, NE2 4HH, Scotland; e-mail: thomas.hellyer@ncl.ac.uk


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Conway Morris has received grants from the Wellcome Trust and UK Department of Health for the study of diagnostic techniques in ventilator-associated pneumonia. Prof Simpson has received funds to attend educational conferences (for travel, accommodation, and registration) from GlaxoSmithKline and Boehringer Ingelheim GmbH; delivered independent lectures at events sponsored by GlaxoSmithKline and Astellas Pharma Inc; and is a coinvestigator with BD on independent, noncommercial grants. Dr Hellyer has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(5):1734-1735. doi:10.1378/chest.13-1478
Text Size: A A A
Published online
To the Editor:

The increasing prevalence of antibiotic resistance is of global concern. With few antibiotic agents in development,1 there is an increasing need for antibiotic stewardship. This is relevant in the ICU where patients receive a large burden of antibiotics and are at risk for infection from antibiotic-resistant pathogens. There is a need to improve antibiotic stewardship in patients with suspected ventilator-associated pneumonia (VAP). Because infection is confirmed by positive culture results in about 30% of patients, the implication is that patients commonly receive antibiotics for noninfective respiratory compromise.

The report by Vallés et al2 in a recent issue of CHEST (May 2013) adds complexity to the difficulties facing clinicians who balance antibiotic stewardship with the best outcome for the patient. This study reported a fall in VAP associated with prophylactic use of a single dose of antibiotics administered at the time of intubation in comatose patients. Data from the United States over the same period reported declining VAP rates in all patient groups.3 The apparent fall in VAP rates has led to debate about whether this represents the success of prevention strategies or changes in the quality of surveillance and reporting. These results need to be validated in a randomized controlled trial before being implemented in routine practice.

Vallés et al2 acknowledged that the main risk of implementing widespread prophylactic antibiotics in the ICU is the emergence of antibiotic-resistant pathogens. Although the choice of antibiotic in this study covers the organisms commonly colonizing sites of potential inoculum before admission to the hospital, this cannot be assumed for all patient groups. The oropharynx of elderly patients admitted from inpatient wards or long-term-care facilities often is colonized by gram-negative bacilli4 and could be at risk for becoming colonized with resistant pathogens following antibiotic exposure. Vallés et al2 did not find an increase in resistant pathogens in the late-onset VAP group, but they did not perform surveillance cultures. Given that this was a small, single-center study, it does not provide sufficient evidence to exclude the possibility that the intervention may promote antibiotic resistance. The apparent reduction in early VAP in comatose patients, although an interesting finding, may be a benefit for a patient group for whom the consequences of VAP are less severe.5 Although these benefits are of potential value, they require confirmation in late VAP for which the clinical consequences are more severe. Ultimately, the aim remains to find better ways of preventing VAP that do not rely on the use of antibiotics.

References

Spellberg B, Powers JH, Brass EP, Miller LG, Edwards JE Jr. Trends in antimicrobial drug development: implications for the future. Clin Infect Dis. 2004;38(9):1279-1286. [CrossRef] [PubMed]
 
Vallés J, Peredo R, Burgueño MJ, et al. Efficacy of single-dose antibiotic against early-onset pneumonia in comatose patients who are ventilated. Chest. 2013;143(5):1219-1225. [CrossRef] [PubMed]
 
Dudeck MA, Horan TC, Peterson KD, et al. National Healthcare Safety Network (NHSN) Report, data summary for 2010, device-associated module. Am J Infect Control. 2011;39(10):798-816. [CrossRef] [PubMed]
 
Palmer LB, Albulak K, Fields S, Filkin AM, Simon S, Smaldone GC. Oral clearance and pathogenic oropharyngeal colonization in the elderly. Am J Respir Crit Care Med. 2001;164(3):464-468. [CrossRef] [PubMed]
 
Cook A, Norwood S, Berne J. Ventilator-associated pneumonia is more common and of less consequence in trauma patients compared with other critically ill patients. J Trauma. 2010;69(5):1083-1091. [CrossRef] [PubMed]
 

Figures

Tables

References

Spellberg B, Powers JH, Brass EP, Miller LG, Edwards JE Jr. Trends in antimicrobial drug development: implications for the future. Clin Infect Dis. 2004;38(9):1279-1286. [CrossRef] [PubMed]
 
Vallés J, Peredo R, Burgueño MJ, et al. Efficacy of single-dose antibiotic against early-onset pneumonia in comatose patients who are ventilated. Chest. 2013;143(5):1219-1225. [CrossRef] [PubMed]
 
Dudeck MA, Horan TC, Peterson KD, et al. National Healthcare Safety Network (NHSN) Report, data summary for 2010, device-associated module. Am J Infect Control. 2011;39(10):798-816. [CrossRef] [PubMed]
 
Palmer LB, Albulak K, Fields S, Filkin AM, Simon S, Smaldone GC. Oral clearance and pathogenic oropharyngeal colonization in the elderly. Am J Respir Crit Care Med. 2001;164(3):464-468. [CrossRef] [PubMed]
 
Cook A, Norwood S, Berne J. Ventilator-associated pneumonia is more common and of less consequence in trauma patients compared with other critically ill patients. J Trauma. 2010;69(5):1083-1091. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543