Department of Pharmacy, University of Louisville Hospital, Louisville, Kentucky, USA.
Department of Surgery, University of Louisville, Louisville, Kentucky, USA.
Surg Infect (Larchmt). 2022 Aug;23(6):597-603. doi: 10.1089/sur.2022.126.
Ventilator-associated pneumonia (VAP) is a frequently occurring nosocomial infection in critically ill trauma patients. When bronchoalveolar lavage (BAL) returns with indigenous oral flora (IOF), de-escalating antimicrobial therapy is challenging. This is a retrospective review of trauma patients who received broad-spectrum empiric antimicrobial therapy for clinical VAP, and whose BAL culture resulted with >100,000 CFU/mL of IOF from September 1, 2017 to September 1, 2020. Patients were identified using the trauma database and microbiology reports of BALs with IOF. This review evaluated the effect of antibiotic de-escalation on recurrent or persistent pneumonia. Of 51 trauma patients with clinical VAP and IOF, 18 patients (35.3%) had antimicrobial agents de-escalated. De-escalation was driven primarily by the discontinuation of vancomycin, with the continuation of a β-lactam antibiotic as monotherapy for the remainder of the treatment course (n = 15; 86.7%). The overall rate of either persistent or recurrent VAP in the cohort was 10%, and this did not differ statistically between those who received de-escalation therapy after isolation of IOF and those who did not (16.7% vs. 6.1%; p = 0.224), however, the incidence of acute kidney injury (AKI) was higher in the non-de-escalation group (39.4% vs. 11.1%; p = 0.034). There was no statistical difference in ventilator days, intensive care unit (ICU) length of stay, or hospital length of stay between treatment groups. Trauma patients who develop VAP with isolated BAL cultures of IOF or mixed flora can safely have anti-methicilllin-resistant (MRSA) antimicrobial agents discontinued, and this may result in decreased rates of AKI.
呼吸机相关性肺炎（VAP）是重症创伤患者中经常发生的医院获得性感染。当支气管肺泡灌洗（BAL）回传时出现固有口腔菌群（IOF）时，降低抗菌治疗的强度具有挑战性。本研究回顾性分析了 2017 年 9 月 1 日至 2020 年 9 月 1 日期间因临床 VAP 接受广谱经验性抗菌治疗且 BAL 培养出 IOF 超过 100,000CFU/mL 的创伤患者。使用创伤数据库和 BAL 中 IOF 的微生物报告来识别患者。本研究评估了抗生素降阶梯对复发性或持续性肺炎的影响。在 51 例因临床 VAP 和 IOF 接受治疗的创伤患者中，18 例（35.3%）患者降低了抗生素的使用强度。降阶梯主要是由于停用万古霉素，β-内酰胺类抗生素单药治疗持续至治疗疗程结束（n=15；86.7%）。该队列中持续性或复发性 VAP 的总发生率为 10%，在 IOF 分离后接受降阶梯治疗的患者和未接受降阶梯治疗的患者之间无统计学差异（16.7%比 6.1%；p=0.224），但是，未接受降阶梯治疗的患者急性肾损伤（AKI）的发生率更高（39.4%比 11.1%；p=0.034）。两组患者的呼吸机使用天数、重症监护病房（ICU）住院时间和总住院时间无统计学差异。在 BAL 培养分离出 IOF 或混合菌群的 VAP 创伤患者中，可以安全地停用抗耐甲氧西林金黄色葡萄球菌（MRSA）的抗生素，并且可能会降低 AKI 的发生率。
