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Overview
Ventilator-associated pneumonia (VAP) is a significant
cause of morbidity and mortality in the ICU. Recent studies have
demonstrated the importance of adequate initial empiric therapy.
These studies have shown an increased mortality for patients treated
with antibiotics, which are ineffective for the organisms isolated
from respiratory secretions. At the same time, overuse of broad
spectrum antibiotic coverage has led to the rise of multi-drug resistant
(MDR) bacteria. The MDR bacteria include both gram-negative organisms
such as pseudomonas, but also gram-positive organisms such as S.
aureus. The beta-lactmases remain a cornerstone of treatment for
Gram negative organisms and they have been extremely popular for
empiric therapy for VAP. However, these drugs can still be neutralized
by the extended spectrum beta-lactamases (ESBL). In some case, the
ESBLs can be induced by antibiotic therapy. In the ICU, where wide
spread antibiotic use is common, ESBLs can render these antibiotics
useless. This has proved a problem with the use of third generation
cephalosporins, such as ceftazidime. In addition, ceftazidime and
other cephalosporins have been recognized as risk factors for methicillin
resistant S. aureus and vancomycin-resistant enterococci (VRE).
Pipercillin/tazobactam is less susceptible to the ESBL and there
is evidence regarding lower rate of MRSA and VRE in patients treated
with pipercillin/tazobactam compared to ceftazidime. However, unopposed
use of pipercillin/tazobactam will only lead to loss of a good antibiotic.
Long-term therapy for VAP needs a balance of appropriate antibiotics
relying on the susceptibility of flora in the ICU.
Learning Objectives
Upon completion of this
activity, you will be able to:
- Understand the importance of appropriate antibiotics
in empiric therapy of ventilator-associated pneumonia (VAP)
- Understand the limitations of using cephalosporins
as the main empiric therapy for VAP
- Design strategies to limit the rate of multi-drug
resistant bacteria in the ICU
Faculty Disclosures
Robert P. Baughman, MD, FCCP
Professor of Medicine, University of Cincinnati
Medical Center, Department of Internal Medicine
Disclosure: Consultant with:following companies:Wyeth, Pharmacia,
Pfizer, Glaxo, Centocor, Immunex, Celgene, and Aventis. Research
funding from: National Institutes of Health, Aventis, Centocor,
Celgene, Boeringer, and Immunex.
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Accreditation Statements
Continuing Medical Education for Physicians
The American College of Chest Physicians (ACCP)
is accredited by the Accreditation Council for Continuing Medical
Education to provide continuing medical education for physicians.
The ACCP takes responsibility for the content, quality, and scientific
integrity of this CME enduring activity.
CME Credits
The ACCP, as a sponsor of this program, designates
this continuing medical activity for up to 1 credit hour in Category
1 of the Physician's Recognition Award of the American Medical Association.
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