_______________________________________________________________ Healthcare-Associated Infections
RECOMMENDED ANTIBIOTIC THERAPY FOR HEALTHCARE-ASSOCIATED PNEUMONIA ACCORDING TO SITE OF CARE
Site of Care General ward
Recommended Regimen
Antipseudomonal cephalosporin, antipseudomonal carbapenem, or extended-spectrum ß-lactam/ß-lactamase inhibitor and antipseudomonal fluoroquinolone or aminoglycoside and anti-MRSA agent (vancomycin or linezolid)
Intensive care unit
Empiric MRSA and double coverage of Pseudomonas pneumonia
Source: [20]
Table 12
Guideline Adherence and Quality Improvement Adherence to guidelines for the prevention of ventilator-asso- ciated pneumonia is low, with surveys of nurses demonstrating rates of adherence to specific preventive measures ranging from 15% to 50% [195; 199]. Adherence to a bundle of prevention strategies (head-of-bed elevation, oral chlorhexidine gel, seda- tion holds, and a weaning protocol), with 70% compliance, led to a significant reduction in ventilator-associated pneumonia, from 32 cases per 1,000 ventilator-days to 12 cases per 1,000 ventilator-days [56]. The IHI how-to guide on preventing ventila- tor-associated pneumonia provides several practical recommen- dations, and posting compliance with the ventilator bundle in a prominent place in the ICU can encourage and motivate staff ( Table 13 ) [201]. The use of physician-led multidisciplinary rounds with team decision making, checklists, and a focus on the ventilator bundle has led to significant reductions in ventilator-associated pneumonia [240; 241; 242]. Moderate strength evidence has shown that the use of audit and feedback and reminder systems improve adherence to an overall ventilator-associated pneumo- nia bundle as well as reduce infection rates [1]. Education ses- sions have also led to enhanced knowledge and practice among healthcare professionals caring for intubated patients [200]. The lack of adherence to guideline-directed treatment of pneu- monia cases associated with healthcare facilities is evidenced by wide variations in practice. For example, one study showed that more than 100 different antibiotic regimens had been prescribed as initial treatment and that de-escalation therapy was used for only 22% of patients [197]. Adherence rates for treatment of pneumonia associated with healthcare facilities have been reported to be lower than rates of adherence to guidelines for treatment of community-acquired pneumonia. In one survey, guideline-recommended antibiotics were used 9% of the time for healthcare-associated pneumonia compared with 78% of the time for community-associated pneumonia [243]. This lack of adherence was not due to unfamiliarity or disagreement with the guidelines; 71% of the survey respon- dents said they were aware of the guidelines, and 79% said they agreed with and practiced according to them. It is reasonable to expect that strategies used to enhance adherence to guidelines in the community-acquired pneumonia setting would also be effective in the setting of hospital-acquired and ventilator- associated pneumonia. Such strategies include feedback on performance, reminder systems, standardized order sets, and education emphasizing outcomes and cost-effectiveness.
cure was not significantly higher for linezolid than for vanco- mycin, although there were trends favoring linezolid in several secondary clinical outcomes, such as clinical cure; duration of ventilation, hospitalization, and stay in ICU; survival time not on a ventilator; and overall survival [237]. The findings led the authors to suggest that the benefit of linezolid may be related to factors other than bacterial clearance. According to a meta-analysis, a short fixed-course (7 or 8 days) of antibiotic therapy may be more appropriate than a prolonged course (10 to 15 days) for patients with ventilator-associated pneumonia not caused by non-fermenting gram-negative bacilli [238]. The short course reduced the recurrence rate of ventilator-associated pneumonia caused by multiresistant organisms without adversely affecting other outcomes. Among patients with non-fermenting gram-negative bacilli, recurrence was greater after the short course. The authors confirmed these findings in a follow-up study published in 2015 [239].
For patients with ventilator-associated pneumonia, the IDSA and the American Thoracic Society recommend a seven-day course of antimicrobial therapy rather than a longer duration. There exist situations in which a shorter or longer duration of
antibiotics may be indicated, depending upon the rate of improvement of clinical, radiologic, and laboratory parameters. (https://www.idsociety.org/practice-guideline/ hap_vap. Last accessed January 26, 2025.) Strength of Recommendation/Level of Evidence : Strong recommendation, moderate-quality evidence Role of Inhaled Antibiotic Therapy For cases of ventilator-associated pneumonia caused by gram- negative bacilli that are susceptible only to aminoglycosides or polymyxins the suggestion is to use both inhaled and systemic antibiotics, rather than systemic antibiotics alone [20]. It is also reasonable to consider adjunctive inhaled antibiotic treat- ment as a last resort for patients who are not responding to intravenous antibiotics alone, whether the infecting organism is or is not multidrug resistant.
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