An antibiotic stewardship exercise in the ICU: building a treatment algorithm for the management of ventilator-associated pneumonia based on local epidemiology and the 2016 Infectious Diseases Society of America/American Thoracic Society guidelines

Figures & data

Table 1 Distribution of bacteria causing VAP according to their antibiotic susceptibility patterns

Organisms	Number of isolates	Percentage from own species (%)	Percentage from total (%) (n=75 isolates)
Gram-negative species	72		96
A. baumanii	28		37.33
MDR	1	3.57	1.33
XDR	26	92.86	34.67
PDR	1	3.57	1.33
P. aeruginosa	23		30.67
TZP S	16	69.57	21.33
TZP R	7	30.43	9.33
CAZ S	17	73.91	22.67
CAZ R	6	26.09	8
FEP S	16	69.57	21.33
FEP R	7	30.43	9.33
AMK S	15	65.22	20
AMK R	8	34.78	10.67
LVX S	18	78.26	24
LVX R	5	21.74	6.67
CAR S	13	56.52	17.33
CAR R	10	43.48	13.33
FEP and LVX R	4	17.39	5.33
TZP and LVX R	4	17.39	5.33
(FEP and LVX R) but CAR S	0	0	0
(TZP and LVX R) but CAR S	1	4.34	1.33
Non-XDR	20	86.96	26.67
XDR	3	13.04	4
Enterobacteriaceae	11		14.67
3GC S	8	72.73	10.67
3GC R	3	27.27	4
TZP S	8	72.73	10.67
TZP R	3	27.27	4
FEP S	9	81.82	12
FEP R	2	18.18	2.67
FQ S	9	81.82	12
FQ R	2	18.18	2.67
CAR S	11	100	14.67
CAR R	0	0	0
FEP and LVX R	1	9.09	1.33
TZP and LVX R	1	9.09	1.33
S. maltophilia	9		12
LVX S	7	77.78	9.33
LVX R	2	22.22	2.67
CAZ S	5	55.56	6.67
CAZ R	4	44.44	5.33
TMP/SMX S	8	88.89	10.67
TMP/SMX R	1	11.11	1.33
CST S^a	NA	NA	NA
XDR^a	1	11.11	1.33
B. cepacia	1		1.33
Gram-positive species	3		4
S. aureus	3		4
MET S	2	66.67	2.67
MET R	1	33.33	1.33

Notes: ^aS. maltophilia is not tested routinely in the hospital for CST susceptibility, unless it is resistant to other alternatives (being an XDR). One isolate was XDR and was found susceptible to CST.

Abbreviations: A. baumannii, Acinetobacter baumannii; AMK, amikacin; B. cepacia, Burkholderia cepacia; CAR, carbapenem; CAZ, ceftazidime; CST, colistin; FEP, cefepime; FQ, fluoroquinolones; LVX, levofloxacin; MDR, multi-drug resistant; MET, methicillin; NA, not available; P. aeruginosa, Pseudomonas aeruginosa; PDR, pandrug resistant; R, resistant; S, susceptible; S. aureus, Staphylococcus aureus; S. maltophilia, Stenotrophomonas maltophilia; TMP/SMX, trimethoprim/sulfamethoxazole; TZP, piperacillin/tazobactam; VAP, ventilator-associated pneumonia; XDR, extensively drug resistant; 3GC, third-generation cephalosporins.

Table 2 Temporal distribution of bacteria causing VAP (number of isolates) over 12-month period from July 2015 to July 2016

Organisms	July2015	August2015	September2015	October2015	November2015	December2015	January2016	February2016	March2016	April2016	May2016	June2016	July2016
A. baumannii	2	1	3	1	2	0	0	4	4	2	2	4	3
XDR	2	1	3	1	1	0	0	4	4	2	1	4	3
P. aeruginosa	1	1	1	1	3	0	0	6	2	0	2	3	3
TZPS	1	1	1	1	2	0	0	4	2	0	2	1	1
FEP S	1	1	1	1	2	0	0	4	1	0	2	2	2
CAZS	1	1	1	1	2	0	0	3	1	0	2	2	2
LVX S	1	1	1	1	2	0	0	5	1	0	2	3	1
FEP or LVX S	1	1	1	1	1	0	0	5	1	0	2	3	2
TZP or LVX S	1	1	1	1	2	0	0	5	2	0	2	3	1
FEP and LVX R	0	0	0	0	0	0	0	0	1	0	0	0	0
TZP and LVX R	0	0	0	0	0	0	0	0	0	0	0	0	1
Non-XDR	1	1	1	1	2	0	0	5	2	0	2	3	2
XDR	0	0	0	0	1	0	0	1	0	0	0	0	1
Enterobacteriaceae	1	0	2	1	0	1	0	0	2	0	1	1	2
LVX S	0	0	1	1	0	1	0	0	2	0	1	1	2
TZPS	1	0	1	1	0	1	0	0	1	0	1	1	1
FEP S	1	0	0	1	0	1	0	0	2	0	1	1	2
3GC S	1	0	0	1	0	1	0	0	1	0	1	1	2
FEP or LVX S	1	0	1	1	0	1	0	0	2	0	1	1	2
TZP or LVX S	1	0	1	1	0	1	0	0	2	0	1	1	2
3GC R	0	0	2	0	0	0	0	0	1	0	0	0	0
FEP and LVX R	0	0	1	0	0	0	0	0	0	0	0	0	0
TZP and LVX R	0	0	1	0	0	0	0	0	0	0	0	0	0
S. maltophilia	0	0	0	0	0	0	1	3	1	0	0	0	4
LVX S	0	0	0	0	0	0	1	3	1	0	0	0	2
CAZS	0	0	0	0	0	0	1	1	0	0	0	0	3
XDR	0	0	0	0	0	0	0	0	0	0	0	0	1
MRSA	0	0	0	0	0	0	0	1	0	0	0	0	0

Abbreviations: A. baumannii, Acinetobacter baumannii; CAZ, ceftazidime; FEP, cefepime, LVX, levofloxacin; MRSA, methicillin-resistant S. aureus; P. aeruginosa, Pseudomonas aeruginosa; R, resistant; S, susceptible; S. aureus, Staphylococcus aureus; S. maltophilia, Stenotrophomonas maltophilia; TZP, piperacillin/tazobactam; VAP, ventilator-associated pneumonia; XDR, extensively drug resistant; 3GC: third-generation cephalosporins.

Figure 1 Antibiotic consumption in the ICU of our facility during the study period (July 2015–July 2016) reported in DDD/100 BD.

Note: x-axis, type of antimicrobial; y-axis, DDD/1000 bed days.
Abbreviations: AMG, aminoglycosides; BD, bed day; CAR, carbapenems; CAZ, ceftazidime; CRO, ceftriaxone; CST, colistin; DDD, defined daily dose; FEP, cefepime; FQ, fluoroquinolones; GLY, glycopeptides (vancomycin and teicoplanin); ICU, intensive care unit; LZD, linezolid; TGC, tigecycline; TZP, piperacillin/tazobactam.

Figure 2 Our proposed treatment algorithm for empiric and targeted treatment of VAP.

Abbreviations: A. baumannii, Acinetobacter baumannii; CAZ, ceftazidime, CRO, ceftriaxone; CST, colistin; DTA, deep tracheal aspirate; FEP, cefepime; IV, intravenous; LVX, levofloxacin; P. aeruginosa, Pseudomonas aeruginosa; S. maltophilia, Stenotrophomonas maltophilia; TMP/SMX, trimethoprim/sulfamethoxazole; TZP, piperacillin/tazobactam; VAP, ventilator-associated pneumonia; XDR, extensively drug resistant; 3GCR, third-generation cephalosporin resistant.