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Ventilator-Associated Pneumonia PreventionVentilator-Associated Pneumonia Prevention: We Still Have a Long Way to Go!

Marin H. Kollef, MD, FCCP
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine.

CORRESPONDENCE TO: Marin H. Kollef, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8052, St Louis, MO 63110; e-mail: mkollef@dom.wustl.edu


FUNDING/SUPPORT: Dr Kollef’s effort was supported by the Barnes-Jewish Hospital Foundation.

FINANCIAL/NONFINANCIAL DISCLOSURES: The author has 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;146(4):873-874. doi:10.1378/chest.14-1066
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In this issue of CHEST (see page 890), Hurley1 performed a multilevel random effects analysis examining topical antibiotics (TAs) for the prevention of ventilator-associated pneumonia (VAP). Because TA use can confer herd protection in the ICU similar to vaccination programs in the community, contextual influences resulting from a population-based intervention cannot be estimated from a single trial. However, multilevel random effects analysis allows the estimation of contextual effects. Hurley1 found that the baseline incidence of VAP derived from observational studies was lower (23.7%; 95% CI, 20.6%-27.2%) than that in studies of TAs using concurrent control groups that either did or did not receive topical placebo (38% [95% CI, 29%-48%] vs 33% [95% CI, 20%-50%], respectively). This observed contextual influence could potentially inflate the apparent effect of TAs, especially within studies using topical placebo. The clinical importance of this observation is illustrated by investigations showing that TAs can promote the emergence of antimicrobial resistance and increase the burden of resistance genes in the gut biome of patients in the ICU.2,3 Without knowing the overall influence of TAs on antimicrobial resistance progression and clinical outcomes, their routine use cannot be endorsed, especially in areas where antibiotic resistance is already a clinically important problem.

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