Update of the Treatment of Nosocomial Pneumonia in the ICU

Rafael Zaragoza; Pablo Vidal-Cortés; Gerardo Aguilar; Marcio Borges; Emili Diaz; Ricard Ferrer; Emilio Maseda; Mercedes Nieto; Francisco Xavier Nuvials; Paula Ramirez; Alejandro Rodriguez; Cruz Soriano; Javier Veganzones; Ignacio Martín-Loeches

Disclosures

Crit Care. 2020;24(383) 

In This Article

Abstract and Introduction

Abstract

In accordance with the recommendations of, amongst others, the Surviving Sepsis Campaign and the recently published European treatment guidelines for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), in the event of a patient with such infections, empirical antibiotic treatment must be appropriate and administered as early as possible. The aim of this manuscript is to update treatment protocols by reviewing recently published studies on the treatment of nosocomial pneumonia in the critically ill patients that require invasive respiratory support and patients with HAP from hospital wards that require invasive mechanical ventilation. An interdisciplinary group of experts, comprising specialists in anaesthesia and resuscitation and in intensive care medicine, updated the epidemiology and antimicrobial resistance and established clinical management priorities based on patients' risk factors. Implementation of rapid diagnostic microbiological techniques available and the new antibiotics recently added to the therapeutic arsenal has been reviewed and updated. After analysis of the categories outlined, some recommendations were suggested, and an algorithm to update empirical and targeted treatment in critically ill patients has also been designed. These aspects are key to improve VAP outcomes because of the severity of patients and possible acquisition of multidrug-resistant organisms (MDROs).

Introduction

In accordance with the recommendations of, amongst others, the Surviving Sepsis Campaign[1] or the latest European treatment guidelines for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP),[2] in the event of a patient with such infections, empirical antibiotic treatment must be appropriate and administered as early as possible. Complying with these conditions is more important and more complex in patients being admitted to an intensive care unit (ICU), both because of the severity of patient and the potential acquisition of multidrug-resistant organisms (MDROs) which will doubtlessly be related to a higher level of unsuitable empirical treatment and, consequently, higher mortality. As an example, when reviewing the data from the National Surveillance Programme of Intensive Care Unit (ICU)-Acquired Infection in Europe Link for Infection Control through Surveillance (ENVIN-HELICS),[3] the likelihood of receiving an inadequate empirical treatment for a Pseudomonas aeruginosa infection, even with combination therapy, is approximately 30%.

The development of new antibiotics and their use should be cautious. In the present manuscript, we propose different algorithms that allow to implement empirical and targeted use for potential MDROs. We must first and foremost capitalize on their greater in vitro activity, lower resistance and suitable efficacy in clinical trials and, secondly, antibiotic diversification and the need for carbapenem-sparing strategies.[4,5] Antimicrobial optimization programmes, such as the US antimicrobial stewardship programmes (ASP), aim to improve the clinical outcomes of patients with nosocomial infections, minimizing adverse effects associated with the use of antimicrobials (including the onset and dissemination of resistance) and guaranteeing the use of cost-effective treatments.[6] In addition, the analysis of its use and results obtained in patients and microbiological resistance result paramount. Avoiding unnecessary treatments and reducing the spectrum and duration of treatment together with the reduction of adverse effects and/or possible interactions will be the ultimate aim.[7,8]

This point of view article summarizes the recently published literature on the management of nosocomial pneumonia in the critically ill patients that require invasive respiratory support, both those arising from hospital wards that ultimately require ICU admission and those associated with mechanical ventilation. Experts were selected on the basis of their contrasted experience in the field of nosocomial infections, including specialists in anaesthesia and in intensive care medicine. An extensive search of the literature was performed by the authors using the MEDLINE/PubMed and Cochrane library databases, from 2009 to October 2019, aimed to retrieve relevant studies on diagnosis and treatment of nosocomial pneumonia in ICU patients especially randomized controlled clinical trials (RCT), systematic reviews, meta-analysis and expert consensus articles. Priorities have been established in regard to the management, agreed by the group and based on risk factors for their development and prognostic factors. Moreover, the most important clinical entities, methods of rapid diagnostics in clinical microbiological available and new antibiotic treatments recently added to the therapeutic options have been reviewed and updated. After the analysis of the priorities outlined, recommendations that can be applied have been included. An algorithm that takes into account the priorities analysed to update empirical and targeted treatment in ICUs has also been designed.

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