по профилактике и лечению внутрибольничной и вентилятор-ассоциированной пневмонии.Новая методика разработки, новые веяния.

Вот ниже основная часть комментария, который доступен по ссылке на Medscape всем подписчикам (бесплатно). Одновременно это и удовольствие рекомендовать один из самых старых образовательных интернет-ресурсов для врачей.

Сами рекомендации тут:
Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. Published online July 14, 2016. http://cid.oxfordjournals.org/content/early/2016/07/06/cid.ciw353.full Accessed July 15, 2016.

Василий Власов

From Medscape Education Clinical Briefs

IDSA/ATS Issues Guidelines for Pneumonia Treatment CME / ABIM MOC / CE

News Author: Tara Haelle
CME Author: Laurie Barclay, MD

 

Clinical Context

The previous 2005 guideline described management of healthcare-associated pneumonia. In contrast, the current guideline differentiates between ventilator-associated pneumonia (VAP) and hospital-acquired pneumonia (HAP), defined as an episode of pneumonia not associated with mechanical ventilation. Approximately one-fifth to one-quarter of all hospital-acquired infections are either HAP or VAP, which are fatal in approximately 10% to 15% of patients.

Unlike the 2005 guideline, the updated version, developed by a multidisciplinary panel, used the Grading of Recommendations Assessment, Development and Evaluation methodology to evaluate all available evidence from recent systematic reviews and meta-analyses.

Study Synopsis and Perspective

In an attempt to balance responsible stewardship of antibiotics with safe, effective treatment of specific hospital-associated infections, new guidelines recommend an antibiotic course lasting 7 days or less for treatment of HAP and VAP: 2 categories that replace the previous inclusive category of healthcare-associated pneumonia.

The new guidelines, issued by the Infectious Diseases Society of America (IDSA) and the American Thoracic Society, also recommend that each hospital develop an antibiogram: a local analysis of the bacterial strains causing pneumonia with a focus on infections in the intensive care unit, along with the antibiotics that successfully treat those bacterial infections.

«Once clinicians are updated regularly on what bugs are causing VAP and HAP in their hospitals as well as their sensitivities to specific antibiotics, they can choose the most effective treatment,» lead author Andre C. Kalil, MD, MPH, from the University of Nebraska Medical Center in Omaha, said in an IDSA news release. These antibiograms help «individualize care, ensuring patients will be treated with the correct antibiotic as soon as possible,» Dr Kalil said in his statement.

The new recommendations were published online July 14 in Clinical Infectious Diseases, and replace the previous set published in 2005.

Multidisciplinary Effort

Dr Kalil led a multidisciplinary panel that developed the guidelines in an attempt to limit the development of antibiotic resistance without compromising patient safety, relying on evidence from recent systematic reviews and meta-analyses. «The findings do not lead to any specific recommendations, rather they provided guidance for the panelists for several of the treatment recommendations,» the authors write.

Together, HAP and VAP account for 20% to 25% of hospital-acquired infections, and an estimated 10% to 15% of these cases result in death. When viewed separately, Dr Kalil and colleagues note that approximately one in 10 patients receiving mechanical ventilators go on to have VAP, and 13% of the infections are fatal.

Yet research has not shown that longer courses of antibiotics have any greater benefit than shorter courses. Longer courses are, however, associated with increased adverse effects such as diarrhea, a greater risk for Clostridium difficile, increased medical costs, and an increased risk for antibiotic resistance.

The authors therefore recommend a 7-day course of antibiotic treatment for VAP and HAP, but they acknowledge that «[t]here exist situations in which a shorter or longer duration of antibiotics may be indicated, depending upon the rate of improvement of clinical, radiologic, and laboratory parameters.» They also recommend de-escalating antimicrobial therapy, using narrow-spectrum antibiotics instead of broad-spectrum ones, and starting with monotherapy instead of combination therapy.

The organizations also «suggest using [procalcitonin] levels plus clinical criteria to guide the discontinuation of antibiotic therapy, rather than clinical criteria alone,» in patients with HAP or VAP, although the authors note that the recommendation is based on relatively low-quality evidence.

Other recommendations focus on using noninvasive methods to diagnose VAP, relying exclusively on clinical criteria to determine whether to begin antibiotic treatment, and choosing empiric treatment options for specific clinical circumstances. Most of these recommendations, however, also rely on low-quality evidence.

In developing antibiograms, the authors recommend that each institution also determine how often the guidelines should be updated. «Considerations should include their rate of change, resources, and the amount of data available for analysis,» the authors write.

The guidelines do include specific recommendations for initial empiric antibiotic therapy based on whether the infection is VAP or HAP, risk for methicillin-resistant Staphylococcus aureus, risk for mortality, and presence of gram-positive or gram-negative antibiotics, among other clinical considerations.

«In patients with suspected VAP, we recommend including coverage for S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli in all empiric regimens,» the authors write. «For patients being treated empirically for HAP, we recommend prescribing an antibiotic with activity against S. aureus.»

The guidelines were developed with financial support for conference calls, meeting space, and administrative support from the IDSA and the American Thoracic Society. No industry funding was used in developing these guidelines. Seven coauthors disclose receiving research grants or advisory or consultancy fees from 1 or more of the following: Allergan, Melinta, Merck, MotifBio, Nabriva, Tetraphase, Sensor Kenesis Group, Pfizer, Cempra, Biofire Diagnostics, Aradigm, Gilead, Bayer, Astellas, Roche, Angellini, Novartis, Nektar Therapeutics, and Infectopharm.

Clin Infect Dis. Published online July 14, 2016.[1]

Study Highlights

  • For a diagnosis of VAP, noninvasive sampling with semi-quantitative cultures is recommended, with use of endotracheal aspiration.
  • If clinicians do perform invasive quantitative cultures on occasion, antibiotics should be withheld if results are below the diagnostic threshold for VAP.
  • Patients with suspected HAP should be treated based on microbiologic studies performed on respiratory samples obtained noninvasively, rather than being treated empirically.
  • Noninvasive methods include spontaneous expectoration, sputum induction, nasotracheal suctioning in an uncooperative patient, and endotracheal aspiration if the patient with HAP subsequently requires mechanical ventilation.
  • The decision whether to start antibiotics in patients with suspected HAP or VAP should be based on clinical criteria alone, rather than adding results from serum procalcitonin, bronchoalveolar lavage fluid for soluble triggering receptor expressed on myeloid cells (sTREM-1), C-reactive protein, or modified Clinical Pulmonary Infection Score (CPIS).
  • The clinical criteria guiding decisions regarding initiation of antibiotics should include the likelihood of another source of infection, previous antimicrobial therapy at time of culture, degree of clinical suspicion, signs of severe sepsis, and evidence of clinical improvement.
  • To guide clinicians regarding the optimal choice of antibiotics, each hospital should develop antibiograms, or local analysis of bacterial strains causing pneumonia, particularly in the intensive care unit, and of antibiotic sensitivity.
  • Each institution should decide on how often antibiograms should be updated, based on rate of change, resources, and quantity of available data.
  • To reduce patient harm and unnecessary antibiotic exposure and to decrease development of antibiotic resistance, clinicians should use the antibiogram to reduce unnecessary use of dual gram-negative and empiric methicillin-resistant S aureus (MRSA) antibiotic therapy.
  • Empiric treatment may be appropriate in certain clinical circumstances, guided by whether the infection is VAP or HAP, risk for MRSA, mortality risk, and other criteria.
  • All empiric regimens for suspected VAP should include coverage for S aureus, P aeruginosa, and other gram-negative bacilli.
  • If empiric treatment is given for HAP, it should be effective against S aureus.
  • Regardless of microbial etiology, most patients with HAP or VAP should receive short-course antibiotic therapy (≤7 days) and antibiotic de-escalation. When prescribing this regimen, clinicians should use narrow-spectrum rather than broad-spectrum antibiotics, favoring monotherapy rather than combination therapy.
  • Longer-term antibiotic treatment is not shown to be more effective but may result in increased adverse effects including diarrhea, a greater risk for C difficile, higher costs, and a greater risk for antibiotic resistance.
  • Antibiotic discontinuation should be guided by procalcitonin levels in addition to clinical criteria (based on relatively low-quality evidence).

Clinical Implications

  • Updated IDSA/ATS guidelines recommend noninvasive sampling with semi-quantitative cultures to diagnose HAP or VAP, and use of clinical criteria alone to guide decisions on whether to start antibiotics.
  • Regardless of microbial etiology, most patients with HAP or VAP should receive short-course antibiotic therapy (≤7 days) and antibiotic de-escalation.
  • Implications for the Healthcare Team: Each hospital should develop antibiograms, or local analysis of bacterial strains causing pneumonia, to guide clinicians regarding the optimal choice of antibiotics.