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Carlos M. Luna, MD, PhD, FCCP; Sergio Sarquis, MD; Ariel Sosa, MD; María Otaola, MD, FCCP; Nicolás Bailleau, MD; Carlos A. Vay, PhD; Célica Irrarzábal, MD; Angela Famiglietti, PhD; Abelardo A. Capdevila, MD; Michael S. Niederman, MD, FCCP
Author and Funding Information

From Pulmonary Diseases Division (Drs Luna, Otaola, and Bailleau), Intensive Care Division (Drs Sarquis, Sosa, Irrarzábal, and Capdevila), Microbiology (Drs Vay and Famiglietti), Hospital de Clinicas, Universidad de Buenos Aires; and Winthrop-University Hospital (Dr Niederman).

Correspondence to: Carlos M. Luna, MD, PhD, FCCP, Pulmonary Diseases Division, Hospital de Clinicas, Universidad de Buenos Aires, Acevedo 1070, Banfield, Buenos Aires, Argentina 1828; e-mail: cymluna@fmed.uba.ar


Financial/nonfinancial disclosures: Dr Luna has participated in advisory boards for Pfizer, Inc; Bayer AG; and AstraZeneca PLC, and has given talks for Pfizer, Inc. All other 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):925-926. doi:10.1378/chest.13-2857
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Published online
To the Editor:

We thank Dr Lee and colleagues for their interest in our recent article in CHEST1 and their comments about some of our findings. They have asked the question, “Why were there fewer days of antimicrobial exposure in the surveillance endotracheal aspirate (ETA) group relative to the guideline-treated group?”

It is important to keep in mind that our study evaluated a theoretical model, performed on the data retrieved from a cohort of patients who were mechanically ventilated, which compared two different strategies in the management of ventilator-associated pneumonia (VAP). This comparison was based on the data retrieved during our surveillance study, when it was extrapolated at the time of the clinical diagnosis of VAP. The duration of appropriate therapy was established to be 10 days in all cases; death of patients was not taken into account. There were fewer antimicrobial-days with the ETA-based strategy because in those cases in which the result of the ETA coincided with the final microbiologic diagnosis of VAP, the result could have been no therapy at all in the ETA-guided therapy, if the result was negative, compared with 2 days of three antimicrobials (this is 6 antimicrobial-days) if the group had received American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guideline-guided therapy. In the great majority of the cases, the therapy suggested by the surveillance cultures was appropriate for the actual pathogen of VAP and required fewer antimicrobial-days than would be necessary in a guideline-based approach. The guideline approach relies on deescalation, and, thus, between 2 and 4 antimicrobial-days would be added, compared with using therapy-guided ETA surveillance cultures. Finally, in those cases in which the therapy based on ETA surveillance cultures was totally or partially inappropriate, the initial prescription would be replaced by a new antimicrobial therapy for 10 days, adding 10 to 20 antimicrobial-days to the one, two, or three antimicrobials administered inappropriately during the first 2 days (2, 4, or 6 antimicrobial-days); in this instance, the sum of antimicrobial-days could be greater, the same, or even less than the number of antimicrobials received if the therapy had been guided by the ATS/IDSA guidelines.

As a consequence of these considerations, the number of antimicrobial-days could be significantly higher with the therapy guided by the ATS/IDSA guidelines than with surveillance cultures, without putting patients at risk of a poor outcome. Even though the instances of inappropriate therapy could be significantly higher using the ETA-guided therapy, some of the difference could be related to the empirical use of dual antipseudomonal therapy when guidelines are followed, even though outcome studies do not support a proven benefit of dual therapy beyond assuring appropriate coverage, which could have already been achieved with a single agent, using surveillance cultures.2 Thus, there are plausible explanations for our findings that could lead to less antimicrobial use and not add to patient risk of adverse outcome.

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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