Nussenblatt Veronique, Avdic Edina, Berenholtz Sean, Daugherty Elizabeth, Hadhazy Eric, Lipsett Pamela A, Maragakis Lisa L, Perl Trish M, Speck Kathleen, Swoboda Sandra M, Ziai Wendy, Cosgrove Sara E
Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Infect Control Hosp Epidemiol. 2014 Mar;35(3):278-84. doi: 10.1086/675279. Epub 2014 Feb 3.
Diagnosing ventilator-associated pneumonia (VAP) is difficult, and misdiagnosis can lead to unnecessary and prolonged antibiotic treatment. We sought to quantify and characterize unjustified antimicrobial use for VAP and identify risk factors for continuation of antibiotics in patients without VAP after 3 days.
Patients suspected of having VAP were identified in 6 adult intensive care units (ICUs) over 1 year. A multidisciplinary adjudication committee determined whether the ICU team's VAP diagnosis and therapy were justified, using clinical, microbiologic, and radiographic data at diagnosis and on day 3. Outcomes included the proportion of VAP events misdiagnosed as and treated for VAP on days 1 and 3 and risk factors for the continuation of antibiotics in patients without VAP after day 3.
Two hundred thirty-one events were identified as possible VAP by the ICUs. On day 1, 135 (58.4%) of them were determined to not have VAP by the committee. Antibiotics were continued for 120 (76%) of 158 events without VAP on day 3. After adjusting for acute physiology and chronic health evaluation II score and requiring vasopressors on day 1, sputum culture collection on day 3 was significantly associated with antibiotic continuation in patients without VAP. Patients without VAP or other infection received 1,183 excess days of antibiotics during the study.
Overdiagnosis and treatment of VAP was common in this study and led to 1,183 excess days of antibiotics in patients with no indication for antibiotics. Clinical differences between non-VAP patients who had antibiotics continued or discontinued were minimal, suggesting that clinician preferences and behaviors contribute to unnecessary prescribing.
诊断呼吸机相关性肺炎（VAP）存在困难，误诊会导致不必要的长期抗生素治疗。我们试图量化并描述针对VAP的不合理抗菌药物使用情况，并确定无VAP患者在3天后继续使用抗生素的风险因素。
在1年时间里，于6个成人重症监护病房（ICU）中识别疑似患有VAP的患者。一个多学科判定委员会利用诊断时及第3天的临床、微生物学和影像学数据，确定ICU团队对VAP的诊断和治疗是否合理。结局指标包括在第1天和第3天被误诊为VAP并接受VAP治疗的事件比例，以及第3天后无VAP患者继续使用抗生素的风险因素。
ICU确定了231起可能为VAP的事件。在第1天，委员会判定其中135起（58.4%）并非VAP。在第3天，158起无VAP的事件中有120起（76%）继续使用了抗生素。在调整急性生理与慢性健康状况评分II以及第1天需要使用血管升压药后，第3天进行痰培养采集与无VAP患者继续使用抗生素显著相关。在研究期间，无VAP或其他感染的患者多接受了1183天的抗生素治疗。
在本研究中，VAP的过度诊断和治疗很常见，导致无抗生素使用指征的患者多接受了1183天的抗生素治疗。继续或停用抗生素的非VAP患者之间的临床差异极小，这表明临床医生的偏好和行为导致了不必要的处方。
