Duration of Treatment for Ventilator-Associated Pneumonia

The article by Dr Beidas asked whether nosocomial pneumonia should be treated for 8 days and questions the basis of this recommendation in the Guidelines for the Management of Adults with Hospital-Acquired Pneumonia, Ventilator Associated Pneumonia. Although it is certainly admirable and appropriate to question new recommendations, I believe that Dr Beidas has erred on 3 counts. First of all, let us examine exactly what the recommendation is. Dr Beidas begins her article with a statement: BIn 2005 the ATS/IDSA Guidelines for the Management of Nosocomial Pneumonia recommended a shortened course (8 days) for the treatment of nonpseudomonas ventilator-associated pneumonia (VAP). [ In fact, what is actually stated is the following: BIf patients receive an initially appropriate antibiotic regimen, efforts should be made to shorten the duration of therapy from the traditional 14 to 21 days to periods as short as 7 days, provided that the etiologic pathogen is not Pseudomonas aeruginosa, and that the patient has a good clinical response with resolution of clinical features of infection. [ The statement by the ATS/IDSA is a carefully worded and carefully qualified one that takes into account 2 critical issues: the use of appropriate antibiotics and the clinical response of the patient. It certainly is not a blanket statement that recommends 8 days of treatment in a perfunctory manner and leaves it at that. In the second sentence of her article, Dr Beidas then states that the recommendation was based upon a study by Chastre et al. This too is somewhat of a misrepresentation of the facts. Although the study by Chastre et al was important and ultimately served as the basis for the level 1 status accorded the new statement by the guidelines, it was by no means the only evidence for this. A discussion of the issue of duration of therapy in the guidelines cites articles by Dennesen et al and Luna et al. Both are observational studies but provided important insights into length of treatment for patients with VAP. Data from both studies suggested that, as long as appropriate antibiotic treatment has been initiated, those patients who will respond do so within several days and prolonged treatment may not be required. The study by Singh et al that used the Clinical Pulmonary Infection Score as a way to reduce unnecessary antibiotic use in the treatment of patients with pulmonary infiltrates in the intensive care unit was able to identify patients at lower risk who could be treated for shorter periods. Finally, she focuses her attention on the article by Chastre et al and its shortcoming in terms of experimental design and methodology, and the Consolidated Standards of Reporting Trials (CONSORT) statement is cited. Ultimately, Dr Beidas asks that the evidence-based level grade applied to the study by Chastre et al be changed from a level 1 to a level 2. The CONSORT statement is certainly an important and helpful contribution to the literature dealing with the methodology of clinical trials and represents the ideal in the reporting of a randomized controlled trial (RCT). It is an indicator of the quality of reporting in a particular RCT, and although it certainly represents a standard to which all investigators should aspire, it is not a criterion for acceptance of a trial nor does failure to fulfill the checklist of items published in the CONSORT statement constitute a basis on which to dismiss a particular RCT. Editorial Comment