The importance of de-escalating antimicrobial therapy in patients with ventilator-associated pneumonia

The management of ventilator-associated pneumonia (VAP) requires a strategy for antibiotic use that achieves prompt and accurate empirical therapy without overusing antibiotics. Although, efforts at better diagnosis and antibiotic restriction have been attempted, "de-escalation" may be a more useful and effective strategy, and one that can achieve these goals while improving patient outcomes. The centerpiece of this approach is to initiate empirical therapy with a broad-spectrum treatment regimen, based on knowledge of local patterns of microbiology and antimicrobial resistance. Prior to therapy, patients require collection of a lower respiratory tract sample for culture. After 2 to 3 days, the clinical course can be assessed and the culture data reviewed, and in responding patients, efforts can be made to change the initial broad-spectrum therapy. This de-escalation can involve focusing to a more narrow spectrum agent, reducing the number of antibiotics, stopping therapy altogether in patients not likely to have infection, and making efforts to reduce duration of therapy. When this strategy has been used, outcomes such as the frequency of secondary infection, antimicrobial resistance, and mortality have improved. Additional information is needed to apply this approach more widely, especially in patients infected with multidrug-resistant organisms and in those with negative lower respiratory tract cultures.