Chest
Volume 125, Issue 5, May 2004, Pages 1791-1799
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Clinical Investigations in Critical Care
A Randomized Controlled Trial of an Antibiotic Discontinuation Policy for Clinically Suspected Ventilator-Associated Pneumonia

https://doi.org/10.1378/chest.125.5.1791Get rights and content

Objective

To evaluate an antibiotic discontinuation policy for clinically suspected ventilator-associated pneumonia (VAP).

Design

Prospective, randomized, controlled clinical trial.

Setting

A medical ICU from a university-affiliated urban teaching hospital.

Patients

Between April 2002 and July 2003, 290 patients completed the clinical trial.

Interventions

Patients were assigned to have the duration of antibiotic treatment for VAP determined by an antibiotic discontinuation policy (discontinuation group) or their treating physician teams (conventional group).

Results

Severity of illness using APACHE (acute physiology and chronic health evaluation) II score (22.8 ± 9.0 vs 23.2 ± 9.4, p = 0.683) [mean ± SD] and the clinical pulmonary infection score (7.1 ± 0.9 vs 7.2 ± 0.9, p = 0.222) were similar for both patient groups. The duration of antibiotic treatment for VAP was statistically shorter among patients in the discontinuation group compared to patients in the conventional antibiotic management group (6.0 ± 4.9 days vs 8.0 ± 5.6 days, p = 0.001). The occurrence of a secondary episode of VAP was not statistically different between these two groups (17.3% vs 19.3%, p = 0.667). Hospital mortality (32.0% vs 37.1%, p = 0.357) and ICU length of stay (6.8 ± 6.1 days vs 7.0 ± 7.3 days, p = 0.798) were also statistically similar.

Conclusions

The application of an antibiotic discontinuation policy for clinically suspected VAP was associated with a decrease in the overall duration of antibiotic treatment. These findings suggest that shorter courses of empiric antibiotic therapy for patients treated for clinically suspected VAP can be safely achieved.

Section snippets

Study Location and Patients

The study was conducted at a university-affiliated urban teaching hospital: Barnes-Jewish Hospital (1,400 beds) in St. Louis, MO. During a 14-month period (April 2002 to July 2003), all patients admitted to the medical ICU (19 beds) were potentially eligible for this investigation. Patients were entered into the study if they were > 18 years old and received antibiotic treatment for VAP. Patients were excluded from participation if they were transferred to the medical ICU due to lack of

Patients

A total of 290 consecutive patients treated with antibiotics for presumed VAP completed the clinical trial (Fig 1). The mean age of the patients was 59.9 ± 17.8 years (range, 19 to 97 years); 145 patients (50.0%) were men, and 145 patients (50.0%) were women. The mean APACHE II score of the entire study cohort was 23.0 ± 9.2 (range, 4 to 50), and the mean clinical pulmonary infection score for the study cohort was 7.1 ± 0.9 (range, 6 to 9). Patients in the two treatment groups were

Discussion

We demonstrated that an antibiotic discontinuation policy directed at the treatment of clinically suspected VAP was associated with the administration of statistically shorter durations of antibiotic therapy. On average, patients managed with the antibiotic discontinuation policy received 2 fewer days of antibiotic treatment compared to patients in the conventional group. No differences in hospital mortality or the durations of intensive care and hospitalization were observed between the two

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    This investigation was supported in part by the Barnes-Jewish Hospital Foundation and an unrestricted grant from Elan Pharmaceuticals.

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