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Jordi Vallés, MD, PhD; Ignacio Martin-Loeches, MD, PhD
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From the Critical Care Department, Corporació Parc Taulí.

Correspondence to: Jordi Vallés, MD, PhD, Corporació Parc Taulí - Critical Care Department, Parc Tauli s/n, Sabadell, Barcelona 08208, Spain; e-mail: jvalles@tauli.cat


Financial/nonfinancial disclosures: The authors have reported to CHEST 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):1735. doi:10.1378/chest.13-1576
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To the Editor:

We thank Dr Hellyer and colleagues for their comments regarding our article on prophylactic use of a single dose of antibiotic administered at the time of intubation in comatose patients.1 We agree that the excess of antibiotic use is associated with a higher risk of acquisition of multiple drug-resistant pathogens. Therefore, in our article, the goal of a prophylactic strategy is focused on a very particular population of comatose patients who are intubated in emergency situations. This group of patients presents a high incidence of early ventilator-associated pneumonia (VAP) (50%-60%),2,3 and, based on the American Thoracic Society/Infectious Diseases Society of America recommendations, it is suggested that prophylactic antibiotic use might be administered within the first 24 h.4 In our study, to rapidly decrease the bacterial burden during intubation, we decided to focus the period of administration of antibiotic within the first 4 h after intubation.

The association of developing resistances to antibiotics has been recognized with the use of prolonged treatments. Furthermore, significant differences in antibiotic resistances have been documented when surgical patients received antibiotic prophylaxis for > 48 h.5 Interestingly, this was the main difference with previous studies that administered more than only one single dose of antibiotic.

We have to acknowledge that with the use of our strategy, the outcome was not different between patients who received prophylaxis and those who did not. However, it is important to highlight the reduction in antibiotic pressure. Dead bugs do not mutate, and, therefore, avoiding early-onset VAP episodes will help avoid prescribing antibiotic therapy with ceftriaxone, quinolone, ampicillin/sulbactam, or ertapenem for 5 to 7 days based on the current American Thoracic Society/Infectious Diseases Society of America guidelines recommendation.

We agree that we should be restrictive with the use of broad-spectrum antibiotics in ICU settings to reduce the acquisition of multiple drug-resistant pathogens. Therefore, we strongly believe that with the use of a single antibiotic dose, the incidence of early VAP decreased and consequently the antibiotic consumption in the ICU decreased (from 60% in control subjects to 30% in the prophylaxis group).1 Rational antibiotic prescription is conceived to optimize antimicrobial therapy, to assure cost-effective therapy while containing bacterial resistance. Although our strategy needs to be further evaluated in a randomized clinical trial, antibiotic stewardship can be easily implemented with a single dose.

References

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]
 
Acquarolo A, Urli T, Perone G, Giannotti C, Candiani A, Latronico N. Antibiotic prophylaxis of early onset pneumonia in critically ill comatose patients. A randomized study. Intensive Care Med. 2005;31(4):510-516. [CrossRef] [PubMed]
 
Perbet S, Mongardon N, Dumas F, et al. Early-onset pneumonia after cardiac arrest: characteristics, risk factors and influence on prognosis. Am J Respir Crit Care Med. 2011;184(9):1048-1054. [CrossRef] [PubMed]
 
American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416. [CrossRef] [PubMed]
 
Habarth S, Samore MH, Lichtenberg D, Carmeli Y. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infection and antimicrobial resistence. Circulation. 2000;101(25):2916-2921. [CrossRef] [PubMed]
 

Figures

Tables

References

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]
 
Acquarolo A, Urli T, Perone G, Giannotti C, Candiani A, Latronico N. Antibiotic prophylaxis of early onset pneumonia in critically ill comatose patients. A randomized study. Intensive Care Med. 2005;31(4):510-516. [CrossRef] [PubMed]
 
Perbet S, Mongardon N, Dumas F, et al. Early-onset pneumonia after cardiac arrest: characteristics, risk factors and influence on prognosis. Am J Respir Crit Care Med. 2011;184(9):1048-1054. [CrossRef] [PubMed]
 
American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416. [CrossRef] [PubMed]
 
Habarth S, Samore MH, Lichtenberg D, Carmeli Y. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infection and antimicrobial resistence. Circulation. 2000;101(25):2916-2921. [CrossRef] [PubMed]
 
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