• Marin H Kollef, Lee E Morrow, Michael S Niederman, Kenneth V Leeper, Antonio Anzueto, Lisa Benz-Scott, and Frank J Rodino.
• Washington University School of Medicine, 660 South Euclid Ave, St. Louis, MO 63110, USA. mkollef@im.wustl.edu
• Chest. 2006 May 1; 129 (5): 1210-8.

Study ObjectivesTo evaluate clinical characteristics and treatment patterns among patients with ventilator-associated pneumonia (VAP), including the implementation of and outcomes associated with deescalation therapy.DesignProspective, observational, cohort study.SettingTwenty ICUs throughout the United States.PatientsA total of 398 ICU patients meeting predefined criteria for suspected VAP.InterventionsProspective, handheld, computer-based data collection regarding routine VAP management according to local institutional practices, including clinical and microbiological characteristics, treatment patterns, and outcomes.Measurements And ResultsThe most frequent ICU admission diagnoses in patients with VAP were postoperative care (15.6%), neurologic conditions (13.3%), sepsis (13.1%), and cardiac complications (10.8%). The mean (+/- SD) duration of mechanical ventilation prior to VAP diagnosis was 7.3 +/- 6.9 days. Major pathogens were identified in 197 patients (49.5%) through either tracheal aspirate or BAL fluid and included primarily methicillin-resistant Staphylococcus aureus (14.8%), Pseudomonas aeruginosa (14.3%), and other Staphylococcus species (8.8%). More than 100 different antibiotic regimens were prescribed as initial VAP treatment, the majority of which included cefepime (30.4%) or a ureidopenicillin/monobactam combination (27.9%). The mean duration of therapy was 11.8 +/- 5.9 days. In the majority of cases (61.6%), therapy was neither escalated nor deescalated. Escalation of therapy occurred in 15.3% of cases, and deescalation occurred in 22.1%. The overall mortality rate was 25.1%, with a mean time to death of 16.2 days (range, 0 to 49 days). The mortality rate was significantly lower among patients in whom therapy was deescalated (17.0%), compared with those experiencing therapy escalation (42.6%) and those in whom therapy was neither escalated nor deescalated (23.7%; chi2= 13.25; p = 0.001).ConclusionsTreatment patterns for VAP vary widely from institution to institution, and the overall mortality rate remains unacceptably high. The deescalation of therapy in VAP patients appears to be associated with a reduction in mortality, which is an association that warrants further clinical study.

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