Seminars in respiratory infections
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Semin Respir Infect · Jun 2003
ReviewWhen can empiric therapy for intensive care unit-acquired pneumonia be withheld or withdrawn?
Diagnosing ventilator-associated pneumonia (VAP) is difficult, creating important clinical dilemmas for intensive care physicians. Adequate empiric antimicrobial therapy is crucial because VAP is associated with increased morbidity and mortality, especially when initial treatment is inappropriate. ⋯ Therefore, a balance should be found between the obvious necessary therapeutic benefits and the negative effects (selection of resistant pathogens, costs, and adverse effects) of antibiotics in the treatment of VAP. Although guidelines for initial antimicrobial therapy have been established, no such recommendations exist for withholding or withdrawing antimicrobial treatment, and little is known about the optimal duration of therapy.
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Semin Respir Infect · Jun 2003
ReviewEffectiveness of programs to decrease antimicrobial resistance in the intensive care unit.
Resistance of microbes to antibiotics is an increasing problem in intensive care units (ICUs) with a prevalence of 86% in some isolates. Resistance results in increased morbidity, mortality, and increased costs. Risk factors associated with the development of resistance and strategies to combat resistance are discussed. ⋯ Changing antimicrobial practices via guideline development, antibiotic restriction, use of information systems technology, crop rotation, narrowing spectrum of empiric antibiotics, multidisciplinary approaches, and selective decontamination have had variable results. Prevention of horizontal transmission via handwashing, glove and gown use, alternatives to soap, and improving the workload and facilities for health care workers is discussed. Primary prevention via decreased length of stay, selective digestive decontamination, vaccine development, and decreased use of invasive devices also plays a role.
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Pneumonia is a very common admission diagnosis of critically ill patients. Patients with severe episodes of pneumonia are at risk for development of the systemic inflammatory response syndrome, which is known to induce the production of proinflammatory cytokines, such as interleukins (ILs) and tumor necrosis factor alpha (TNF-alpha). ⋯ Some of these mediators can be proapoptotic or antiapoptotic. This article discusses the clinical implications of the systemic response to pneumonia in the critically ill patient.