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Correspondence |

Antimicrobial Guidance in Ventilator-Associated Pneumonia With Routine Endotracheal CulturesAntibiotics for Ventilator-Associated Pneumonia FREE TO VIEW

Sarah J. Lee, MD; Kelly Cawcutt, MD; Teng Moua, MD
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine (Drs Lee, Cawcutt, and Moua) and Division of Infectious Disease (Dr Cawcutt), Mayo Clinic.

Correspondence to: Sarah J. Lee, MD, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Ave NW, Rochester, MN 55902; e-mail: lee.sarah3@mayo.edu.


Editor’s Note: Authors are invited to respond to Correspondence that cites their previously published work. Those responses appear after the related letter. In cases where there is no response, the author of the original article declined to respond or did not reply to our invitation.

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. 2014;145(4):925. doi:10.1378/chest.13-2764
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To the Editor:

In an issue of CHEST (July 2013), Luna et al1 presented a well-designed study to help elucidate the controversy on routine surveillance respiratory cultures to guide antibiotic treatment of ventilator-associated pneumonia (VAP) compared with the current practice of empirical, broad-spectrum antibiotic therapy with deescalation based on American Thoracic Society/Infectious Diseases Society of America guidelines. We commend the authors on their effort in using a prospective randomized protocol hybridized with a generated theoretical outcome for their intervention arm, such that no patients were harmed in this study. However, their findings did raise a question we cannot answer: Why were there fewer days of antimicrobial exposure in the surveillance endotracheal aspirate (ETA) group relative to the guideline-treated group?

It was unclear from the article if the length of duration was shorter in the ETA group due to death foreshortening the planned time frame or if a short duration was intentional, thus, leading to death from inadequate dosing, which is a possible confounding factor of the difference in outcomes between the two groups. Their hypothesized protocol involved holding off on the initiation of antibiotics with a negative ETA. A delay in antibiotic administration is known to be associated with mortality, so empirical antibiotics in suspected VAP are recommended prior to any culture results.2 With the risk of mortality outweighing the benefit of expediting deescalation of antimicrobials, most physicians will not change this practice. Those treated based on guidelines would be expected to have a shorter duration as the days on empirical therapy could be factored into the overall planned duration, while the ETA group will need a longer antibiotic duration with drug escalation. The authors also did not state clearly if the guideline-treated group had stopped treatment with antimicrobials within 48 to 72 h based on negative BAL or if the duration often deviated from the 7- to 8-day minimum or 10-day Pseudomonas recommended treatment to longer regimens based on clinician preference.

In an era of increasing antimicrobial resistance, the need for antibiotic stewardship is important, and we applaud the authors in investigating a modality that could potentially shorten antimicrobial duration. However, due to the risk of excessive mortality and morbidity of VAP, our conclusion is that we will not change our clinical practice from the current recommended guidelines.

References

Luna CM, Sarquis S, Niederman MS, et al. Is a strategy based on routine endotracheal cultures the best way to prescribe antibiotics in ventilator-associated pneumonia? Chest. 2013;144(1):63-71. [CrossRef]
 
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]
 

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References

Luna CM, Sarquis S, Niederman MS, et al. Is a strategy based on routine endotracheal cultures the best way to prescribe antibiotics in ventilator-associated pneumonia? Chest. 2013;144(1):63-71. [CrossRef]
 
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]
 
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