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Pre-emptive broad-spectrum treatment for ventilator-associated pneumonia in high-risk patients

Abstract

Purpose

Patients requiring mechanical ventilation (MV) for >48 h after major heart surgery (MHS) are at a high risk of acquiring ventilator-associated pneumonia (VAP) and tracheobronchitis (VAT). Most non-pharmacological interventions to prevent VAP in such patients are usually already implemented. The objective of this study was to evaluate the efficacy in preventing lower respiratory infections of antibiotics active against multidrug-resistant pathogens in this very high-risk population.

Methods

We performed a prospective randomized open-label study of MHS patients requiring MV for >48 h. Patients were randomly allocated to one of two groups: the intervention group, which received a 3-day course of linezolid and meropenem, and the control group, which received the standard of care. The main outcome was the development of VAP or VAT.

Results

Overall, of the 78 patients included in the study, 40 were in the intervention group and 38 in the control group. Both groups were comparable. Data for the intervention and control groups respectively were as follows: VAP + VAT/1,000 days was 31.79 vs 64.78 (p = 0.03), median length of MV before the first episode of VAP or VAT 9 vs 4.5 days (p = 0.02). No significant differences were observed in median length of stay in the intensive care unit, median length of hospital stay, antibiotic use, Clostridium difficile infection, and overall mortality rate. We detected linezolid-resistant coagulase-negative and coagulase-positive staphylococci in the MHS intensive care unit after the study period.

Conclusions

A pre-emptive approach with broad-spectrum antibiotics may be effective in reducing the incidence and delaying the onset of VAP + VAT after MHS. The ecological consequences have to be carefully evaluated in future trials.

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Abbreviations

ASA:

American Society of Anesthesiologists

CASS:

Continuous aspiration of subglottic secretions

CDI:

Clostridium difficile infection

CDC:

Centers for Disease Control and Prevention

DDDs:

Daily defined doses

EuroSCORE:

European System for Cardiac Operative Risk Evaluation

EA:

Endotracheal aspirates

ICU:

Intensive care unit

IQR:

Interquartile range

LRTI:

Lower respiratory tract infections

MHS:

Major heart surgery

MV:

Mechanical ventilation

NYH:

New York Heart Association

SD:

Standard deviation

VAP:

Ventilator-associated pneumonia

VAT:

Ventilator-associated tracheobronchitis

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Acknowledgments

We thank Thomas O’Boyle for his help in the preparation of the English version of the manuscript and Cristina Fernández for the statistical analysis. Supported in part by Ciber de Enfermedades Respiratorias (CIBERES) and by the Rafael del Pino Foundation. This study was partially supported by grants from the Fondo de Investigación Sanitaria FIS PI070896, FIS PIO9/1257, and FISPI10/02869 (Instituto de Salud Carlos III).

Conflicts of interest

None of the authors have any conflicts of interest to declare.

Author information

Correspondence to María Jesús Pérez Granda.

Additional information

This article is discussed in the editorial available at doi:10.1007/s00134-013-2983-z.

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Bouza, E., Granda, M.J.P., Hortal, J. et al. Pre-emptive broad-spectrum treatment for ventilator-associated pneumonia in high-risk patients. Intensive Care Med 39, 1547–1555 (2013). https://doi.org/10.1007/s00134-013-2997-6

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Keywords

  • Ventilator-associated pneumonia
  • Prevention
  • Major heart surgery
  • Pre-emptive treatment
  • Intensive care
  • Linezolid
  • Meropenem