In this episode, I’ll discuss whether gram stain–guided initial antibiotic therapy for VAP is better than guideline recommended therapy.
VAP guidelines recommend initial broad spectrum coverage often with an anti-MRSA and anti-pseudomonal agent. These antibiotics are then to be narrowed as more clinical information becomes available.
Gram-stain guided therapy offers the chance to avoid unnecessary antibiotic use but until now was not well studied.
A group of researchers as published in JAMA the GRACE-VAP Randomized Clinical Trial which sought to compare the clinical response to Gram stain–guided restrictive antibiotic therapy vs guideline-based broad-spectrum antibiotic treatment in patients with ventilator-associated pneumonia (VAP).
This was a multicenter, open-label, noninferiority randomized clinical trial of 206 ICU patients with VAP.
The Gram stain results were categorized as gram-positive cocci (GPC) chains, GPC clusters, gram-positive bacilli, gram-negative rods (GNR), or a combination of these.
The restrictive group protocol called for the following:
A nonpseudomonal β-lactam antibiotic was administered when Gram stain results showed only GPC chains and/or gram-positive bacilli.
An anti-MRSA agent was administered when Gram stain results showed GPC clusters without GNR.
An antipseudomonal agent was administered when Gram stain results showed GNR without GPC clusters.
The combination of an antipseudomonal agent and anti-MRSA agent was administered when Gram stain results showed both GPC clusters and GNR.
Patients in the guideline group received an antipseudomonal agent and an anti-MRSA agent.
A positive clinical response occurred in 77% of patients in the Gram stain–guided group and 72% of patients in the guideline-based group, which met the pre-specified criteria for non-inferiority of the Gram stain-guided protocol.
As would be expected, the Gram stain-guided group had significantly reduced use of anti-MRSA and anti-pseudomonal antibiotics.
No significant differences were found between groups in secondary outcomes such as ICU-free days, ventilator-free days, and adverse events.
The authors concluded:
Results of this trial showed that Gram stain–guided treatment was noninferior to guideline-based treatment and significantly reduced the use of broad-spectrum antibiotics in patients with VAP. Gram staining can potentially ameliorate the multidrug-resistant organisms in the critical care setting.
The most recent IDSA VAP guidelines are from 2016 and the IDSA lists them as current, so it will be interesting to see if the guidelines go to development soon and whether they will incorporate this evidence as potentially antibiotic-sparing therapy.
To access my free download area with 20 different resources to help you in your practice, go to pharmacyjoe.com/free.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
Leave a Reply