FROM CLINICAL INFECTIOUS DISEASES
A 1-week course of antibiotics is sufficient for most hospital-acquired and ventilator-associated pneumonia, regardless of the microbial etiology of the infection, according to an updated Clinical Practice Guidelines for managing adults with these disorders.
In addition, every hospital should develop its own antibiogram to align clinicians’ choice of treatments with the local distribution of likely pathogens and their antimicrobial susceptibilities. Both of these recommendations, as well as others that are also new to the updated guidelines, are intended to minimize patient exposure to unnecessary antibiotics and reduce antibiotic resistance, said Andre C. Kalil, MD , and Mark L. Metersky, MD , cochairs of the guidelines panel of 18 experts in infectious diseases, pulmonary medicine, critical care medicine, laboratory medicine, microbiology, pharmacology, and guideline methodology.
For the same reason, the updated guidelines also recommends that each hospital’s antibiogram be used to steer clinicians away from unnecessary dual therapy with gram-negative plus empiric anti–Methicillin-resistant Staphylococcus aureus (MRSA) agents, said Dr. Kalil, of the division of infectious diseases at the University of Nebraska Medical Center, Omaha, and Dr. Metersky, of the division of pulmonary and critical care medicine at the University of Connecticut, Farmington.
The guidelines, an update of the last version issued in 2005 and developed jointly by representatives of the Infectious Disease Society of America (including Dr. Kalil) and the American Thoracic Society (including Dr. Metersky), are intended for use by all clinicians who care for patients at risk for hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP), including surgeons, anesthesiologists, and hospitalists as well as specialists in infectious diseases, pulmonary diseases, and critical care. The guidelines no longer use the concept of health care–associated pneumonia (HCAP), chiefly because new evidence shows that designation is too general: HCAP patients are not at high risk for multidrug-resistant organisms simply because of their contact with the health care system, the guidelines panel wrote ( Clin Infect Dis. 2016 Sep 1;63:e61-e111 ).
The IDSA/ATS Guidelines strongly recommend short-course (1-week) antibiotic therapy instead of longer courses for both HAP and VAP and assert that antibiotic doses should be de-escalated rather than fixed. It advises that serum procalcitonin level plus clinical criteria, not just clinical criteria alone, should be used to guide antibiotic discontinuation, and suggests that the Clinical Pulmonary Infection Score not be used to guide discontinuation.
Regarding individual antibiograms for all hospitals, the guidelines recommend that medical centers regularly create and disseminate a local antibiogram, ideally one that is specific to its intensive-care population. Each facility should determine the frequency for doing so, based on its resources, the rate of change of pathogens at the hospital, and the amount of data available to inform the antibiogram.
The guidelines also address empiric treatments when MRSA is suspected and give detailed guidance for selecting antibiotics once the causative organism is identified, including Pseudomonas aeruginosa, extended-spectrum beta-lactamase–producing gram-negative bacilli, Acinetobacter species, and pathogens resistant to carbapenem.
The guidelines include numerous other recommendations concerning the diagnosis of HAP and VAP, the optimal initial treatments, the pharmacokinetic and pharmacodynamic optimization of antibiotic therapies, and the use of inhaled antibiotics. All the recommendations “are a compromise between the competing goals of providing early appropriate antibiotic coverage and avoiding superfluous treatment that may lead to adverse drug effects, Clostridium difficile infections, antibiotic resistance, and increased costs,” the guidelines panel noted.
The full-text guidelines, including details about the panel’s methodology in reviewing the current literature and the summaries of evidence that support each recommendation, is available free on the Clinical Infectious Diseases website .
The Infectious Diseases Society of America and the American Thoracic Society provided financial and administrative support to develop the guidelines. No industry funding was permitted. Dr. Kalil reported having no potential conflicts of interest; Dr. Metersky reported ties to Aradigm, Gilead, Pfizer, Bayer, and their associates reported ties to numerous industry sources.
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