Evans Cory R, Sharpe John P, Swanson Joseph M, Wood G Christopher, Fabian Timothy C, Croce Martin A, Magnotti Louis J
Department of Surgery, University of Tennessee Health Science Center , Memphis, Tennessee.
Surg Infect (Larchmt). 2018 Oct;19(7):672-678. doi: 10.1089/sur.2018.087. Epub 2018 Sep 11.
An integral part of ventilator-associated pneumonia (VAP) therapy is the appropriate choice of empiric antibiotics. Our previous experience demonstrated adherence to an empiric therapy pathway was associated with only modest changes in organisms causing VAP. The purpose of the current study was to evaluate the impact of a restrictive antibiotic policy for VAP in trauma patients on the incidence and sensitivities of causative pathogens since the previous study.
Patients with VAP diagnosed on bronchoalveolar lavage since the previous study were stratified by age, gender, mechanism of injury, and injury severity. All patients received empiric antibiotics based on duration of intensive care unit (ICU) stay using a unit-specific pathway. The incidence and sensitivities of causative pathogens in the current study were documented. The adequacy of the VAP pathway was evaluated for all VAP episodes. The current study was then compared with the previous study.
Over a 10-year period, 1,474 episodes of VAP were diagnosed with 2,387 causative pathogens isolated. Overall incidence of gram-positive and gram-negative VAP pathogens was unchanged between the study periods. The current study experienced an increase in the incidence of Staphylococcus aureus (23% vs. 17%, p = 0.001) and methicillin-resistant Staphylococcus aureus (10% vs. 6%, p = 0.002) compared with the previous study. The pathway for empiric antibiotics resulted in adequate empiric coverage in 85% of VAP episodes, which was improved compared with the previous study (76%, p = 0.024). Furthermore, despite the increased incidence of early methicillin-resistant Staphylococcus aureus (MRSA) VAP, adequacy of the pathway improved for both the early period (91% vs. 86%, p = 0.001) as well as the late period (86% vs. 63%, p < 0.001) in the current study compared with the previous study.
A comprehensive protocol for the diagnosis and management of VAP, along with antibiotic stewardship, can prevent the development of bacterial resistance to empiric therapy.
呼吸机相关性肺炎（VAP）治疗的一个重要组成部分是经验性抗生素的恰当选择。我们之前的经验表明，遵循经验性治疗路径仅会使导致VAP的病原体发生适度变化。本研究的目的是评估自之前的研究以来，针对创伤患者VAP的限制性抗生素政策对致病病原体的发生率和敏感性的影响。
自之前的研究以来，通过支气管肺泡灌洗诊断为VAP的患者按年龄、性别、损伤机制和损伤严重程度进行分层。所有患者根据重症监护病房（ICU）住院时间，采用特定科室的路径接受经验性抗生素治疗。记录本研究中致病病原体的发生率和敏感性。对所有VAP发作评估VAP路径的充分性。然后将本研究与之前的研究进行比较。
在10年期间，共诊断出1474例VAP发作，分离出2387种致病病原体。研究期间革兰氏阳性和革兰氏阴性VAP病原体的总体发生率没有变化。与之前的研究相比，本研究中金黄色葡萄球菌的发生率有所增加（23%对17%，p = 0.001），耐甲氧西林金黄色葡萄球菌的发生率也有所增加（10%对6%，p = 0.002）。经验性抗生素治疗路径在85%的VAP发作中实现了充分的经验性覆盖，与之前的研究（76%）相比有所改善（p = 0.024）。此外，尽管早期耐甲氧西林金黄色葡萄球菌（MRSA）VAP的发生率有所增加，但与之前的研究相比，本研究中早期（91%对86%，p = 0.001）和晚期（86%对63%，p < 0.001）的路径充分性均有所提高。
VAP诊断和管理的综合方案，以及抗生素管理，可以预防细菌对经验性治疗产生耐药性。
