PURPOSE: Determine if a clinical guideline increased the initial administration of appropriate empiric anti-microbial treatment to trauma patients with ventilator associated pneumonia (VAP). Secondary objectives evaluated duration of mechanical ventilation, ICU and hospital lengths of stay (LOS), drug cost of VAP treatment, and development of super-infection.
METHODS: A VAP guideline for diagnosis and treatment was developed with the guidelines of the American College of Chest Physicians and institution's antibiogram. Once VAP was diagnosed, cultures were obtained and intravenous antibiotics were started within twelve hours--vancomycin 15 mg/kg (renal ajusted dosing), ciprofloxacin 400 mg every eight hours, and piperacillin/tazobactam 4.5 grams every six hours. Once culture and susceptibilities were received, treatment was modified, and limited to seven days. Prospectively enrolled patients were compared to a retrospective cohort before the guideline. Super infection was defined as developing an infection with Serratia, Pseudomonas, Acinetobacter, Citrobacter, Enterobacter, or MRSA. T-test and Chi squared analysis had significance assigned at p < 0.05.
RESULTS: Forty-nine trauma patients comprise this study; 36 retrospective (12/2002 through 7/2003) and 13 prospective (12/2003 through 12/2004). Before the guideline only 1/36 (2.8%) received appropriate initial antibiotics; after implementation 4/13 patients (30.8%) received appropriate initial antibiotics at maximal doses, a significant improvement. Prospective patients had shoter duration of ventilation and ICU LOS just missing statitiscal validity and hospital lengths of stay were statistically lower in the prospective study group. The mean cost of VAP antibiotic treatment per patient for the retrospective group was significantly higher than the prospective group. Super-infection developed in 29/36 patients (80.6%) in the retrospective group, 8/13 patients (61.5%) developed a super-infection in the prospective group, a decrease which just missed statistical significance.
CONCLUSION: The guideline diagnosed VAP more carefully decreasing unnecessary antibiotics and ultimately cost of treatment. It also increased appropriate initial treatment and decreased length of hospital stay, time on mechanical ventilation and super infections.
CLINICAL IMPLICATIONS: Precisely defining diagnosis, evidence based treatment plans and reduced therapeutic variation improved outcome in complex trauma ICU patients.
DISCLOSURE: Scott Newbrough, None.
Scott Newbrough MD * Nikki Freeman PharmD Brian J. Daley MD Dana Taylor MD Ed Varnadoe PharmD UTMCK, Knoxville, TN
COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group
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