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Management of ventilator-associated pneumonia Ibrahim EH, et al. Crit care Med 2001;29:1109-15. Comparison of Shorter versus Longer Duration of Therapy for VAP After initiating of guideline: Similar mortality, shorter hospital stay Lower occurrence of secondary VAP Multi-drug resistant pathogen more frequently in patients treated for 15 days For uncertain pathogen of VAP and response to treatment occur within first 6 days ? 7-8 day therapy is sufficient ! Ibrahim EH, et al. Crit care Med 2001;29:1109-15. Rello J, et al. Crit Care Med 2004;32:2183-90. Chastre J, et al. JAMA 2003;290:2588-98. Rotating (cycling) antibiotics Antibiotic Cycling vs. Diversity Cycling (Rotation) Diversity Models and clinical trials shown that heterogeneous antibiotic use is a potential way of reducing the selection pressure that leads to antibiotic resistance Brown EM . J Antimicrob Chemother. 2005;55:6-9. Fridkin SK. Clin Infect Dis. 2003;36:1438-44. Bergstrom CT. Proc Natl Acad Sci USA. 2004;101:13285-90. Bonhoeffer S. Proc Natl Acad Sci USA. 1997;94:12106-11. Bonten MJ. Clin Infect Dis. 2001;33:1739-46. Sandiumenge A. J Antimicrob Chemother. 2006;57:1197-204. Cycling vs. Mixing and Selective Pressure on a Bacterial Clone Bergstrom CT, et al. Proc Natl Acad Sci. 2004;101:13285-13290. Mixing use of antibiotic offers greater heterogeneity Restriction use of 3rd-cephalosporin ESBL-K. pneumoniae outbreak at ICU Associated with 3rd cephem use Restriction use of 3rd ceph., substitute to imipenem Decrease ESBL-KP, but lead to IMP-R Acinetobacter (metallo-b-lactamase) and P. aeruginosa (loss porins) Pena, et al. AAC 1998;42:53-7. Impact of cephalosporin restriction 44% reduction of ESBL K. pneumoniae 68% increased IMP-resistant P. aeruginosa Rahal, et al. JAMA 1998;280:1233-7. Infection Control to Prevent MDR-bacterial infection A. baumannii VRE; MRSA Pseudomonas S. maltoph
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