Rotation of antimicrobial therapy in the intensive care unit: impact on incidence of ventilator-associated pneumonia caused by antibiotic-resistant Gram-negative bacteria

Abstract

The development of antibiotic resistance is associated with high morbidity and mortality, particularly in the intensive care unit (ICU) setting. We evaluated the effect of an antibiotic rotation programme on the incidence of ventilator-associated pneumonia (VAP) caused by antibiotic-resistant Gram-negative bacteria. We conducted a 2-year before-and-after study at two medical-surgical ICUs at two different tertiary referral hospitals. We included all mechanically ventilated patients admitted for ≥48 h who developed VAP. . Conversely, the number of VAP caused by Pseudomonas aeruginosa passed from 8.35 per 1,000 days of MV in P1 to 2.33 per 1,000 days of MV in P2 (p=0.02). No difference in ICU mortality and crude in-hospital mortality between P1 and P2 was noted. Moreover, no significant change of microbial flora isolated through clinical cultures was observed. We were able to conclude that, despite global microbial flora not being affected by such a programme, antibiotic therapy rotation may reduce the incidence of VAP caused by antibiotic-resistant Gram-negative bacteria in the ICU, such as Pseudomonas aeruginosa. The application of this programme may also improve antibiotic susceptibility. However, further studies are needed to confirm our results.

Antibiotic heterogeneity: from concept to practice

“…Yet again, the investigation disappointingly showed beneficial effects only in a certain subgroup of bacterial population, such as fewer cases of VAP caused by P. aeruginosa (8.35 per 1,000 days of mechanical ventilation in the first period and 2.33 per 1,000 days of mechanical ventilation in the rotation period; P = 0.02). The investigators did not detect a significant difference in ICU mortality 35 . Thus, the benefit of cycling programs might be limited to specific subsets of resistant bacteria.…”

Recent trends in antibiotic resistance in European ICUs

“…In a two-centre Italian trial, rotation of cephalosporins, fluoroquinolones, carbapenems and piperacillin-tazobactam during 12 months was associated with a nonsignificant reduction of the incidence of VAP caused by Gram-negative bacteria, including antibiotic-resistant bacteria, without determinable effects on LOS or ICU-mortality [70]. In a two-centre Italian trial, rotation of cephalosporins, fluoroquinolones, carbapenems and piperacillin-tazobactam during 12 months was associated with a nonsignificant reduction of the incidence of VAP caused by Gram-negative bacteria, including antibiotic-resistant bacteria, without determinable effects on LOS or ICU-mortality [70].…”

Antibiotic Rotation for Febrile Neutropenic Patients with Hematological Malignancies: Clinical Significance of Antibiotic Heterogeneity

“…The efficacy of antibiotic cycling on the recovery of antimicrobial susceptibility and patient mortality is controversial. Several trials have successfully reported a recovery of susceptibility to specific antibiotics or a reduction in detection rates of multidrug-resistant bacteria [4]–[9]. Moreover, some studies have shown a significant decrease in mortality as a result of the trial [4], [5].…”