Update on management options in the treatment of nosocomial and ventilator assisted pneumonia: review of actual guidelines and economic aspects of therapy

Infection and Drug Resistance Dovepress open access to scientific and medical research Review Infection and Drug Resistance downloaded from https://www.dovepress.com/ by 213.32.59.121 on 13-Jul-2018 For personal use only. Open Access Full Text Article Update on management options in the treatment of nosocomial and ventilator assisted pneumonia: review of actual guidelines and economic aspects of therapy This article was published in the following Dove Press journal: Infection and Drug Resistance 18 December 2013 Number of times this article has been viewed Michael Wilke 1 Rolf Grube 1 1 Dr. Wilke GmbH, Munich, Germany Correspondence: Michael Wilke Dr Wilke GmbH, Josep-Wild-Str 13, D-81829 München, Germany Tel +49 89 1890 83760 Fax +49 89 1890 8376-9 Email 1 submit your manuscript | www.dovepress.com Infection and Drug Resistance 2014:7 1–7 Dovepress © 2014 Wilke and Grube. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php http://dx.doi.org/10.2147/IDR.S25985 Powered by TCPDF (www.tcpdf.org) Objective: Nosocomial or more exactly, hospital-acquired (HAP) and ventilator-associated pneumonia (VAP) are frequent conditions when treating intensive care unit (ICU) patients that are only exceeded by central line−associated bloodstream infections. In Germany, approximately 18,900 patients per year suffer from a VAP and another 4,200 from HAP. We therefore reviewed the current guidelines about HAP and VAP, from different sources, regarding the strategies to address individual patient risks and medication strategies for initial intravenous antibiotic treatment (IIAT). Material and methods: We conducted an analysis of the recent guidelines for the treatment of HAP. The current guidelines of the American Thoracic Society, the treatment recommendations of the Paul-Ehrlich-Gesellschaft (PEG), the guidelines from the British Society for Antimicrobial Chemotherapy, the VAP guideline of the Canadian Critical Care trials group, as well as the new German S3-guideline for HAP were examined. Results: All guidelines are based on grading systems that assess the evidence underlying the recommendations. However, each guideline uses different grading systems. One common aspect of these guidelines is the risk assessment of the patients for decision making regarding IIAT. Most guidelines have different recommendations depending on the risk of the presence of multidrug resistant (MDR) bacteria. In guidelines using risk assessment, for low-risk patients (early onset, no MDR risk) aminopenicillins with beta-lactamase inhibitors (BLI), second or third generation cephalosporins, quinolones, or ertapenem are recommended. For patients with higher risk, imipenem, meropenem, fourth generation cephalosporins, ceftazidime or piperacillin/tazobactam are recommended. The PEG recommendations include a combination therapy in cases of very high risk (late onset, MDR risk, ICU, and organ failure) of either piperacillin/tazobactam, dori-, imi- or meropenem or cefepime or ceftazidime with ciprofloxacin, levofloxacin, fosfomycin or an aminoglycoside. For the treatment of HAP caused by methicillin-resistant Staphylococcus aureus (MRSA), either linezolid or vancomycin is recommended. With regard to the ZEPHyR-trial, linezolid has shown higher cure rates but, no difference in overall survival. Economic analyses show the relevance of guideline-adherent IIAT (GA-IIAT). Besides significantly better clinical outcomes, patients with GA-IIAT cause significantly lower costs (€28,033 versus (vs) €36,139) (P=0.006) and have a shorter length of stay in hospital (23.9 vs 28.3 days) (P=0.022). Conclusion: We conclude that most current treatment guidelines take into account the individual patient risk and that the correct choice of IIAT affects clinical as well as economical outcomes. Keywords: nosocomial pneumonia, ventilator, assoc. pneumonia, antibiotics, guidelines, review Wilke and Grube Dovepress Table 1 Synopsis of grading systems used in the respective guidelines Infection and Drug Resistance downloaded from https://www.dovepress.com/ by 213.32.59.121 on 13-Jul-2018 For personal use only. Grading Ref ATS Level I (high) Evidence comes from well-conducted, randomized, controlled trials Level II (moderate) Evidence comes from well-designed, controlled trials without randomization (including cohort, patient series, and casecontrol studies). Level II studies also include any large case series in which systematic analysis of disease patterns and/or microbial etiology was conducted, as well as reports of new therapies that were not collected in a randomized fashion Level III (low) Evidence comes from case studies and expert opinion. In some instances, therapy recommendations come from antibiotic susceptibility data without clinical observations BSAC A At least one meta-analysis, systematic review, or RCT rated as 1++ and directly applicable to the target population; or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results B A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1+ C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 2++ D Evidence level 3 or 4; or extrapolated evidence from studies rated as 2+ Good clinical practice points Recommended best practice based on the clinical experience of the guideline development group 1++ High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias 1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias 1Meta-analyses, systematic reviews, or RCTs with a high risk of bias 2++ High-quality systematic reviews of case control or cohort studies. High-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal 2+ Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal 2Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal 3 Nonanalytic studies, eg, case (...truncated)