Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit - A proposed solution for indiscriminate antibiotic prescription

Inappropriate antibiotic use for pulmonary infiltrates is common in the int ensive care unit (ICU). We sought to devise an approach that would minimize unnecessary antibiotic use, recognizing that a gold standard for the diagn osis of nosocomial pneumonia does not exist. In a randomized trial, clinica l pulmonary infection score (CPIS) (Pugin, J., R. Auckenthaler, N. Mili, J. P. Janssens, R. D. Lew, and P. M. Suter. Diagnosis of ventilator-associate d pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic "blind" bronchoalveolar ravage fluid. Am. Rev. Respir. Dis. 1991;143:1121- 1129) was used as operational criteria for decision-making regarding antibi otic therapy. Patients with CPIS less than or equal to 6 (implying low like lihood of pneumonia) were randomized to receive either standard therapy (ch oice and duration of antibiotics at the discretion of physicians) or ciprof loxacin monotherapy with reevaluation at 3 d; ciprofloxacin was discontinue d if CPIS remained less than or equal to 6 at 3 d. Antibiotics were continu ed beyond 3 d in 90% (38 of 42) of the patients in the standard as therapy compared with 28% (11 of 39) in the experimental therapy group (p = 0.0001) . In patients in whom CPIS remained less than or equal to 6 at the 3 d eval uation point, antibiotics were still continued in 96% (24 of 25) in the sta ndard therapy group but in 0% (0 of 25) of the patients in the experimental therapy group (p = 0.0001). Mortality and length of ICU stay did not diffe r despite a shorter duration (p = 0.0001) and lower cost (p = 0.003) of ant imicrobial therapy in the experimental as compared with the standard therap y arm. Antimicrobial resistance, or superinfections, or both, developed in 15% (5 of 37) of the patients in the experimental versus 35% (14 of 37) of the patients in the standard therapy group (p = 0.017). Thus, overtreatment with antibiotics is widely prevalent, but unnecessary in most patients wit h pulmonary infiltrates in the ICU. The operational criteria used, regardle ss of the precise definition of pneumonia, accurately identified patients w ith pulmonary infiltrates for whom monotherapy with a short course of antib iotics was appropriate. Such an approach led to significantly lower antimic robial therapy costs, antimicrobial resistance, and superinfections without adversely affecting the length of stay or mortality.