comparison of 8 vs 15 days of antibiotics therapy for ventilator ...课件

Comparisonof8vs15DaysofAntibioticsTherapyforVentilator AssociatedPneumoniainadultJAMA November19 2003Vol 290 No 19 R2曾政森加護病房July2005 Introduction HospitalsandparticularlyICUsandrapiddisseminationofmultiresistantbacteria NosocomialpneumoniainpatientsrequiringventilatorrepresentsoneoftheprinciplereasonsfortheprescriptionofantibioticsinICU TheoptimaldurationofantibioticTx forVAP ShorteningthedurationofantibioticsTx Patient sprognosis Riskofrelapse Objective Todeterminewhether8daysisaseffectiveas15daysofantibiotictreatmentofpatientswithmicrobiologicallyprovenVAP Studydesignandorganization Randomized double blindtrialon2parallelgroupsin51ICUsinFrance May1999 June2002 Inclusioncriteria ICUpatients intubatedandreceivedventilator 48hrOlderthan18y oClinicalsuspicionofVAPPositivequantitativeculturesofdistalpulmonarysecretionsamples obtainedbybronchoscopeInstigationwithin24hrfollowingbronchoscopeofappropriateempiricalantibiotics ClinicalsuspicionofVAPNewandpersistentinfiltrateonCXR andWithatleast1ofthefollowing purulenttrachealsecretions BT 38 3oC WBC 10000 L PositivequantitativeculturesofdistallungsecretionBronchoscopiclavage 104CFU mlBronchoscopicbrushing 103CFU ml Exclusioncriteria PregnancyPatientswhowereenrolledinothertrialLittlechangeofsurvival SAPSII 65 Neutropenia WBC 1000 LorNeur 500 L AIDSReceiveimmunosuppressantsorlong termsteroidtherapyConcomitantextrapulmonaryinfection Randomization Patientswererandomlyassignedtoreceiveantibioticsfor8or15days3daysafterbronchoscope Thepathogenswerewellcoveredbyinitialempiricalantibiotics Computer generatedrandom numbertable Antibioticstreatment Drugselectionwaslefttothediscretionofthetreatingphysicians Atleastanaminoglycosideorafluoroquinoloneandabroad spectrumbetalactamantimicrobialagentConvertthisinitialregimenintoanarrowspectrumtherapybasedoncultureresults Follow upanddefinition BT WBC PaO2 FiO2 trachealsecretions ventilatorstatus vitalsignsandODINscore dailyF USOFAandCXRonday3 7 14 21and28Bronchoscopewasperformedbeforetheintroductionofanynewantibiotics Definitionofrecurrence relapse multiresistantbacteria numberofantibiotics freeday ventilator freeday organfailure freeday ODIN OrganDysfunctionand orInfectionscore SOFA Sepsis relatedOrganFailureAssessmentscore Recurrence atleast1bacterialspeciesgrewatasignificantconcentrationfromsamplescollectedduringasecondbronchoscopeRelapse atleast1oftheinitialcausativebacterialstrainsgrewatasignificantconcentrationfromaseconddistalsampleMultiresistantbacteria Ticarcillin resistantP a A b orS m Enterobacteriaceae ESBL MRSA Outcomemeasure Primaryoutcome deathofanycause recurrence antibiotics freedaysSecondaryoutcome ventilator freedays organfailure freedays SOFA ODINscores evolutionofS Ss rateofunfavorableoutcome death recurrence prescriptionofnewantibiotics Antibiotictherapy AminoglycosideorFluoroquinolone betalactam Onday1 179 90 9 of197patientsin8 daygroup187 91 7 of204patientsin15 daygroup Onday8 63 32 8 of192patientsin8 daygroup63 39 2 of199patientsin15 daygroupVancomycinuseonthe1stdayofstudy 39 ofpatientsin8 daygroup 37 ofpatientsin15 daygroup Notably amongpatientswhodevelopedrecurrentpulmonaryinfections multiresistantpathogensemergedsignificantlylessfrequentlyinthosewhohadreceived8daysofantibiotics 42 1 vs62 3 ofrecurrentinfections P 0 04 Comment Nobenefittoprolongingantibioticsto15daysfroman8 dayregimen Theaveragenumberofantibiotic freedaysfromday1today28was50 higherforpatientsin8 daygroup Multiresistantpathogensemergedmorefrequentlyforpatientswithpulmonaryinfectionrecurrencewhohadreceived15daysofantibiotics SlightmorepatientswithnonfementingGNBin8 daygrouphadpulmonaryinfectionrecurrences Comment Despitethishigherrecurrencerate neitherthemortalitynorunfavorableoutcomeratewashigherforpatientsin8 daygroup The8daysofantibioticscouldbesafelyimplementedforallpatientswithVAP includingnonfermentingGNB Bronchoscopeshouldbeperformedassoonaspossiblewhenrelapseissuspect