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Pharmacodynamic-based clinical pathway for empiric antibiotic choice in patients with ventilator-associated pneumonia

Anthony M Nicasio1, Kathryn J Eagye, David P Nicolau

  • 1Center for Antiinfective Research and Development, Hartford Hospital, Hartford, CT 06102, USA.

Journal of Critical Care
|May 12, 2009
PubMed
Abstract

Insights

Implementing a ventilator-associated pneumonia (VAP) clinical pathway using unit-specific data and pharmacodynamic modeling significantly reduced infection-related mortality and length of stay in intensive care units (ICUs). This approach effectively treated multidrug-resistant bacteria.

Area of Science:

  • Infectious Diseases
  • Critical Care Medicine
  • Pharmacology

Background:

  • High prevalence of multidrug-resistant bacteria in intensive care units (ICUs).
  • Implementation of a ventilator-associated pneumonia (VAP) clinical pathway in three ICUs.
  • Pathway based on unit-specific minimum inhibitory concentration (MIC) distributions and pharmacodynamic modeling.

Purpose of the Study:

  • To evaluate the effectiveness of a VAP clinical pathway in reducing mortality and length of stay.
  • To optimize antibiotic regimens for treating VAP caused by multidrug-resistant bacteria.
  • To assess the impact of pharmacodynamic dosing strategies on patient outcomes.

Main Methods:

  • Prospective, observational study with a historical control group (n=168).
  • Monte Carlo simulation to determine optimal antibiotic regimens against Pseudomonas aeruginosa.
  • Integration of selected antibiotic regimens into an ICU-specific computerized clinical pathway.

Main Results:

  • Pharmacodynamic modeling identified 3-hour infusions of cefepime or meropenem with tobramycin and vancomycin as optimal empiric VAP treatment.
  • Significant reduction in infection-related mortality (69%, P = .029).
  • Shorter infection-related length of stay (11.7 vs 26.1 days, P < .001) and fewer superinfections observed.

Conclusions:

  • An ICU-specific approach combining antibiotic MIC data and pharmacodynamic dosing improves outcomes for VAP.
  • This strategy is effective in ICUs with high rates of multidrug-resistant bacteria.
  • High-dose, extended infusion regimens successfully treated nonsusceptible P. aeruginosa.

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