Early use of imipenem/cilastatin and vancomycin followed by de-escalation versus conventional antimicrobials without de-escalation for patients with hospital-acquired pneumonia in a medical ICU: a randomized clinical trial.
Crit Care. 2012 Feb 15;16(1):R28
Authors: Kim JW, Chung J, Choi SH, Jang HJ, Hong SB, Lim CM, Koh Y
Abstract
ABSTRACT: INTRODUCTION: Although early use of broad spectrum antimicrobials in critically ill patients may increase antimicrobial adequacy, uncontrolled use of these agents may select for more resistant organisms. This study investigated the effects of early use of broad spectrum antimicrobials in critically ill patients with hospital-acquired pneumonia. METHODS: We compared the early use of broad spectrum antimicrobials plus subsequent de-escalation (DE) with conventional antimicrobial treatment (non-de-escalation, NDE) in critically ill patients with hospital-acquired pneumonia (HAP). This open-label, randomized clinical trial was performed in patients in a tertiary-care center medical intensive care unit (MICU) in Korea. Patients (n = 54) randomized to the DE group received initial imipenem/cilastatin plus vancomycin with subsequent de-escalation according to culture results, whereas patients randomized to the NDE group (n = 55) received non-carbapenem, non-vancomycin empirical antimicrobials. RESULTS: Between November 2004 and October 2006, 109 MICU patients with HAP were enrolled. Initial antimicrobial adequacy was significantly higher in the DE than in the NDE group for Gram-positive organisms (100% vs. 14.3%; P < 0.001), but not for Gram-negative organisms (64.3% vs. 85.7%; P = 0.190). Mean intensive care unit (ICU) stay, and 14 day, 28 day and overall mortality rates did not differ in the two groups. Among culture-positive patients, mortality from methicillin-resistant Staphylococcus aureus (MRSA) pneumonia was higher in the DE group, even after early administration of vancomycin. Multidrug-resistant organisms, especially MRSA, were more likely to emerge in the DE group (adjusted hazard ratio for emergence of MRSA, 3.84; 95% confidence interval, 1.0613.91). CONCLUSIONS: Therapeutic advantage of early administration of broad spectrum antimicrobials, especially with vancomycin, was not evident in this study.
PMID: 22336530 [PubMed - as supplied by publisher]