Advertisement

International Journal of Clinical Pharmacy

, Volume 39, Issue 4, pp 906–912 | Cite as

A retrospective study of antibiotic de-escalation in patients with ventilator-associated pneumonia in Malaysia

  • Rahela Ambaras Khan
  • Zoriah AzizEmail author
Research Article

Abstract

Background Antibiotic de-escalation is an important strategy to conserve the effectiveness of broad-spectrum antibiotics. However, the outcome of this strategy for the treatment of ventilator-associated pneumonia (VAP) has not been widely studied in developing countries. Objectives To evaluate the outcome on intensive care unit (ICU) mortality, 28 days mortality, and length of ICU stay among VAP patients who receive de-escalation therapy. Setting This study was conducted in an ICU of a Malaysian public hospital. Method The electronic medical records of patients who developed VAP in the ICU were retrieved and relevant data was collected. Records of antibiotic prescriptions were also reviewed to collect the details of changes to antibiotic therapy (de-escalation). Main outcome measure Impact of antibiotic de-escalation on mortality. Results The mean age of the 108 patients was 46.2 ± 18.2 years; the majority being males (80%). The antibiotic de-escalation rate was about 30%. Out of this, 84% involved a change from broad to narrow-spectrum antibiotics and the remaining, withdrawal of one or more antibiotics. ICU mortality was 23% while 28 days mortality was 37%. There was no statistically significant difference in mortality rate, survival probability and the mean length of ICU stay between the de-escalation and the non-de-escalation group. However, patients with Simplified Acute Physiology Score II of ≥50 were significantly associated with ICU mortality and 28 days mortality. Conclusions In VAP patients, antibiotic de-escalation provides an opportunity to promote the judicious use of antibiotics without affecting the clinical outcomes.

Keywords

Antibiotic de-escalation Critically-ill patients Intensive care unit Malaysia Ventilator-associated pneumonia 

Notes

Acknowledgements

The authors wish to thank the Director-General of Health, Malaysia for the permission to publish this paper. We are grateful to Dr. Shanthi Ratnam, Consultant Intensivist of Sungai Buloh Hospital, Dr. Suresh Kumar, Consultant Infectious Disease of Sungai Buloh Hospital and Dr. Kalaiarasu Peariasamy, Senior Consultant and Head of Paediatric Dentistry of Sungai Buloh Hospital and Siti Salwa Mohd Latib for their support towards this research project. We are also thankful to Faculty of Medicine of the University of Malaya and, Clinical Research Centre and Pharmacy Department of Sungai Buloh Hospital for their technical support.

Funding

None.

Conflicts of interest

The authors declare no conflict of interest.

References

  1. 1.
    Kollef MH, Kollef KE. Antibiotic utilization and outcomes for patients with clinically suspected ventilator-associated pneumonia and negative quantitative BAL culture results. Chest. 2005;128:2706–13.CrossRefPubMedGoogle Scholar
  2. 2.
    Iannella HA, Luna CM. Treatment failure in ventilator associated pneumonia. Curr Respir Med Rev. 2012;8:239–44.CrossRefGoogle Scholar
  3. 3.
    Iregui M, Ward S, Sherman G, Fraser VJ, Kollef MH. Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia. Chest. 2002;122:262–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Joung MK, Lee JA, Moon SY, Cheong HS, Joo EJ, Ha YE, et al. Impact of de-escalation therapy on clinical outcomes for intensive care unit-acquired pneumonia. Crit Care. 2011;15:79–86.CrossRefGoogle Scholar
  5. 5.
    Knaak E, Cavalieri SJ, Elsasser GN, Preheim LC, Gonitzke A, Destache CJ. Does antibiotic de-escalation for nosocomial pneumonia impact intensive care unit length of stay? Infect Dis Clin Pract. 2013;21:172–6.CrossRefGoogle Scholar
  6. 6.
    Kollef MH, Sherman G, Ward S, Fraser VJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest. 1999;115:462–74.CrossRefPubMedGoogle Scholar
  7. 7.
    Leone M, Garcin F, Bouvenot J, Boyadjev I, Visintini P, Albanèse J, et al. Ventilator-associated pneumonia: breaking the vicious circle of antibiotic overuse. Crit Care Med. 2007;35:379–85.CrossRefPubMedGoogle Scholar
  8. 8.
    Leroy O, Meybeck A, d’Escrivan T, Devos P, Kipnis E, Georges H. Impact of adequacy of initial antimicrobial therapy on the prognosis of patients with ventilator-associated pneumonia. Intensive Care Med. 2003;29:2170–3.CrossRefPubMedGoogle Scholar
  9. 9.
    Luna CM, Vujacich P, Niederman MS, Vay C, Gherardi C, Matera J, et al. Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia. Chest. 1997;111:676–85.CrossRefPubMedGoogle Scholar
  10. 10.
    Rello J, Vidaur L, Sandiumenge A, Rodríguez A, Gualis B, Boque C, et al. De-escalation therapy in ventilator-associated pneumonia. Crit Care Med. 2004;32:2183–90.CrossRefPubMedGoogle Scholar
  11. 11.
    Torres A, Aznar R, Gatell JM, Jimenez P, Gonzalez J, Ferrer A, et al. Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients. Am Rev Respir Dis. 1990;142:523–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Micek ST, Ward S, Fraser VJ, Kollef MH. A randomized controlled trial of an antibiotic discontinuation policy for clinically suspected ventilator-associated pneumonia. Chest. 2004;125:1791–9.CrossRefPubMedGoogle Scholar
  13. 13.
    Niederman MS. The importance of de-escalating antimicrobial therapy in patients with ventilator-associated pneumonia. Semin Respir Crit Care Med. 2006;27:45–50.CrossRefPubMedGoogle Scholar
  14. 14.
    Alvarez-Lerma F, Alvarez B, Luque P, Ruiz F, Dominguez-Roldan JM, Quintana E, et al. Empiric broad-spectrum antibiotic therapy of nosocomial pneumonia in the intensive care unit: a prospective observational study. Crit Care. 2006;10:78–88.CrossRefGoogle Scholar
  15. 15.
    Eachempati SR, Hydo LJ, Shou J, Barie PS. Does de-escalation of antibiotic therapy for ventilator-associated pneumonia affect the likelihood of recurrent pneumonia or mortality in critically ill surgical patients? J Trauma. 2009;66:1343–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Giantsou E, Liratzopoulos N, Efraimidou E, Panopoulou M, Alepopoulou E, Kartali-Ktenidou S, et al. De-escalation therapy rates are significantly higher by bronchoalveolar lavage than by tracheal aspirate. Intensive Care Med. 2007;33:1533–40.CrossRefPubMedGoogle Scholar
  17. 17.
    Hoffken G, Niederman M. Nosocomial pneumonia: the importance of a de-escalating strategy for antibiotic treatment of pneumonia in the ICU. Chest. 2002;122:2183–96.CrossRefPubMedGoogle Scholar
  18. 18.
    Joffe AR, Muscedere J, Marshall JC, Su Y, Heyland DK. The safety of targeted antibiotic therapy for ventilator-associated pneumonia: a multicenter observational study. J Crit Care. 2008;23:82–90.CrossRefPubMedGoogle Scholar
  19. 19.
    Khan RA, Bakry MM, Islahudin F. Appropriate antibiotic administration in critically Ill patients with pneumonia. Indian J Pharm Sci. 2015;77:299–305.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Kim JW, Chung J, Choi SH, Jang HJ, Hong SB, Lim CM, et al. Early use of imipenem/cilastatin and vancomycin followed by de-escalation versus conventional antimicrobials without de-escalation for patients with hospital-acquired pneumonia in a medical ICU: a randomized clinical trial. Crit Care. 2012;16:28–36.CrossRefGoogle Scholar
  21. 21.
    Kollef MH, Morrow LE, Niederman MS, Leeper KV, Anzueto A, Benz-Scott L, et al. Clinical characteristics and treatment patterns among patients with ventilator-associated pneumonia. Chest. 2006;129:1210–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Soo Hoo GW, Wen YE, Nguyen TV, Goetz MB. Impact of clinical guidelines in the management of severe hospital-acquired pneumonia*. Chest. 2005;128:2778–87.CrossRefPubMedGoogle Scholar
  23. 23.
    Charles MVP, Kali A, Easow JM, Joseph NM, Ravishankar M, Srinivasan S, et al. Ventilator-associated pneumonia. Aust Med J. 2014;7:334–44.CrossRefGoogle Scholar
  24. 24.
    Gonzalez L, Cravoisy A, Barraud D, Conrad M, Nace L, Lemarié J, et al. Factors influencing the implementation of antibiotic de-escalation and impact of this strategy in critically ill patients. Crit Care. 2013;17:R140.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Khasawneh FA, Karim A, Mahmood T, Ahmed S, Jaffri SF, Mehmood M. Safety and feasibility of antibiotic de-escalation in bacteremic pneumonia. Infect Drug Resist. 2014;7:177–82.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Morel J, Casoetto J, Jospé R, Aubert G, Terrana R, Dumont A, et al. De-escalation as part of a global strategy of empiric antibiotherapy management. A retrospective study in a medico-surgical intensive care unit. Crit Care. 2010;14:225–31.CrossRefGoogle Scholar
  27. 27.
    Malani AN, Richards PG, Kapila S, Otto MH, Czerwinski J, Singal B. Clinical and economic outcomes from a community hospital’s antimicrobial stewardship program. Am J Infect Control. 2013;41:145–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Dellit TH, Owens RC, McGowan JE, Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44:159–77.CrossRefPubMedGoogle Scholar
  29. 29.
    Kaki R, Elligsen M, Walker S, Simor A, Palmay L, Daneman N. Impact of antimicrobial stewardship in critical care: a systematic review. J Antimicrob Chemother. 2011;66:1223–30.CrossRefPubMedGoogle Scholar
  30. 30.
    Kollef MH, Micek ST. Antimicrobial stewardship programs: mandatory for all ICUs. Crit Care. 2012;16:179–80.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Lawrence KL, Kollef MH. Antimicrobial stewardship in the intensive care unit. Am J Respir Crit Care Med. 2009;179:434–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Aryee A, Price N. Antimicrobial stewardship—can we afford to do without it? Br J Clin Pharmacol. 2015;79:173–81.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Souza-Oliveira AC, Cunhaa TM, Passos LB, Lopes GC, Gomes FA, Röder DV, et al. Ventilator-associated pneumonia: the influence of bacterial resistance, prescription errors, and de-escalation of antimicrobial therapy on mortality rates. Braz J Infect Dis. 2016;20:437–43.CrossRefPubMedGoogle Scholar
  34. 34.
    Bajpai S, Karnad DR. De-escalation of antibiotics in nosocomial pneumonia in an Indian intensive care unit. Int J Med Med Sci. 2010;2:148–52.Google Scholar
  35. 35.
    Moraes RB, Guillén JAV, Zabaleta WJC, Borges FK. De-escalation, adequacy of antibiotic therapy and culture positivity in septic patients: an observational study. Rev Bras Ter Intensiva. 2016;28:315–22.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Jakkinaboina S, Deepak KS. De-escalation of empiric antibiotic therapy in sepsis—an indian observational study. Intensive Care Med Exp. 2015;3:A405.CrossRefPubMedCentralGoogle Scholar
  37. 37.
    Salahuddin N, Amer L, Joseph M, Kamal A, Elhazmi A, Abouchala N, et al. De-escalation of empiric antibiotics in severe sepsis: situational analysis. Cri Care Med. 2013;41:A234.CrossRefGoogle Scholar
  38. 38.
    Bhakta A, Bhattacharyya M, Todi S. De-escalation practice pattern in an Indian intensive care unit. Crit Care. 2010;14:P63.CrossRefPubMedCentralGoogle Scholar
  39. 39.
    Apisarnthanarak A, Bhooanusas N, Yaprasert A, Mundy LM. Carbapenem de-escalation therapy in a resource-limited setting. Infect Control Hosp Epidemiol. 2013;34:1310–3.CrossRefPubMedGoogle Scholar
  40. 40.
    Allegranzi B, Nejad SB, Combescure C, Graafman W, Attar H, Donaldson L, et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet. 2011;377:228–41.CrossRefPubMedGoogle Scholar
  41. 41.
    Rosenthal VD. Health-care-associated infections in developing countries. The Lancet. 2010;377:186–8.CrossRefGoogle Scholar
  42. 42.
    Rosenthal VD, Al-Abdely HM, El-Kholy AA, AlKhawaja SA, Leblebicioglu H, Mehta Y, et al. International nosocomial infection control consortium report, data summary of 50 countries for 2010–2015: device-associated module. Am J Infect Control. 2016;44:1495–504.CrossRefPubMedGoogle Scholar
  43. 43.
    Vincent J, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, et al. International study of the prevalence and outcomes of infection in intensive care units. JAMA. 2009;302:2323–9.CrossRefPubMedGoogle Scholar
  44. 44.
    American Thoracic Society. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:388–416.CrossRefGoogle Scholar
  45. 45.
    Khan RA, Aziz Z. Antibiotic de-escalation therapy in neurosurgical patients with ventilator-associated pneumonia in intensive care unit: a Retrospective Observational Study. Indian J Pharm Educ Res. 2017;51:144–9.CrossRefGoogle Scholar
  46. 46.
    von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med. 2007;147:573–7.CrossRefGoogle Scholar
  47. 47.
    Tabah A, Cotta MO, Garnacho-Montero J, Schouten J, Roberts JA, Lipman J, et al. A systematic review of the definitions, determinants and clinical outcomes of antimicrobial de-escalation in the intensive care unit. Clin Infect Dis. 2016;62:1009–17.CrossRefPubMedGoogle Scholar
  48. 48.
    Boyce JM, Pop OF, Abreu-Lanfranco O, Hung WY, Fisher A, Karjoo A, et al. A trial of discontinuation of empiric vancomycin therapy in patients with suspected methicillin-resistant staphylococcus aureus health care-associated pneumonia. Antimicrob Agents Chemother. 2013;57:1163–8.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Carlet J, Jarlier V, Harbarth S, Voss A, Goossens H, Pittet D. Ready for a world without antibiotics? The pensières antibiotic resistance call to action. Antimicrob Resist Infect Control. 2012;1:11–23.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Bauer KA, Perez KK, Forrest GN, Goff DA. Review of rapid diagnostic tests used by antimicrobial stewardship programs. Clin Infect Dis. 2014;59:134–45.CrossRefGoogle Scholar
  51. 51.
    Le Gall JR, Lemeshow S, Saulnier F. A new simplified acute physiology score (SAPSII) based on a European/North American multicenter study. JAMA. 1993;270:2957–63.CrossRefGoogle Scholar
  52. 52.
    Minne L, Abu-Hanna A, de Jonge E. Evaluation of SOFA-based models for predicting mortality in the ICU: a systematic review. Crit Care. 2008;12:161–73.CrossRefGoogle Scholar
  53. 53.
    Gursel G, Demirtas S. Value of APACHE II, SOFA and CPIS Scores in predicting prognosis in patients with ventilator-associated pneumonia. Respiration. 2006;73:503–8.CrossRefPubMedGoogle Scholar
  54. 54.
    Fishbain J, Peleg AY. Treatment of Acinetobacter infections. Clin Infect Dis. 2010;51:79–84.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Department of Pharmacy, Faculty of MedicineUniversity MalayaKuala LumpurMalaysia

Personalised recommendations