Empirical antibiotic therapy with a broad-spectrum antibiotic followed by de-escalation does not lead to the selection of resistance to gram (-) pathogens in patients with respiratory pneumonia
Empirical antibiotic therapy with a broad-spectrum antibiotic followed by de-escalation does not increase antibiotic resistance in patients with respiratory pneumonia.
Earlier, the start of empirical antibacterial therapy with a broad-spectrum antibiotic followed by a change in medication with a narrower action in accordance with the identified bacterial pathogen (de-escalation) is the norm for the management of patients with pneumonia respiratory (VAP).
Based on the intensive care unit of the surgical hospital of the Marikop County Medical Center (Phoenix, Arizona, United States), imipenem / cilastatin in combination with tobramycin or levofloxacin is used as a starting treatment in patients with VAP until the quantitative results of a bronchoalveolar lavage study are obtained, after which patients are transferred to antibiotic therapy with a narrower spectrum of action in accordance with the selected bacterial pathogen. However, with this practice, there are concerns regarding the formation of antibiotic resistance in pathogens. The researchers hypothesized that such a rigorous approach to the use of antibiotics does not reduce the sensitivity of the most common Gram-negative causative agents of PVA in a specific surgical intensive care unit.
After approval by the establishment's Expert Council, on the basis of this hospital, a retrospective analysis of the antibiotic sensitivity of the gram-negative pathogens of VAP was carried out for the periods from January to June 2005 (beginning of period) and from July to December 2006 (end of period). During the study, data on empiric antibiotic therapy and subsequent therapy (de-escalation) were collected and compared.
For empirical antibacterial therapy, PAV with imipenem / cilastatin was used 198 times (811 patient days), while tobramycin and levofloxacin were prescribed 149 times (564 patient days) and 61 times (320 days- respectively) patients). In general, for all pathogens, the sensitivity of Gram-negative pathogens to imipenem / cilastatin has not changed (early period 91.4%, late 97%, p = 0.33). With regard to individual pathogens, there was a slight statistically significant increase in Pseudomonas aeruginosa strains sensitive to imipenem / cilastatin (early period 85.7%, late period 90.9% , p = 0.73) and Acinetobacter baumannii (early period 80%, late period 100%, p = 0.13). Both tobramycin and levofloxacin retained activity against Gram-negative pathogens during the study periods (tobramycin: early period 77.1%, late - 70.7%, p = 0.49; levofloxacin: period early 74.3%, late - 70.0%, p = 0.67). The resistance level of Gram-positive pathogens isolated from patients with respiratory pneumonia also did not change during the study.
Adherence to de-escalation tactics (i.e. a change in antibacterial treatment taking certain pathogens into account within 96 hours) was 78% for imipenem / cilastatin, 77.2% for tobramycin and 59% for levofloxacin. When infectious diseases requiring imipenem / cilastatin were removed from the analysis, compliance increased to 92%.
Thus, earlier initiation of empirical antibiotic therapy with a broad spectrum antibiotic followed by a switch to a narrow spectrum antibiotic in accordance with the selected bacterial pathogen does not lead to an increase in antibiotic resistance and is a reasonable tactic for patient management.