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Article Dans Une Revue Critical Care Année : 2024

Antibiotic definitive treatment in ventilator associated pneumonia caused by AmpC-producing Enterobacterales in critically ill patients: a prospective multicenter observational study

Matthieu Petit
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Frank Bidar
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Quentin Fosse
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Lucie Lefevre
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Marine Paul
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Tomas Urbina
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Paul Masi
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Florent Bavozet
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Jérémie Lemarié
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Chloé Andriamifidy-Berti
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Julien Dessajan
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Benjamin Zuber
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Lara Zafrani
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Edwige Peju
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Paris Meng
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Liliane Charrier
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Loic Le Guennec
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Marie Simon
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Charles-Edouard Luyt
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Luc Haudebourg
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Guillaume Geri
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Résumé

Background: Ventilator associated pneumonia (VAP) due to wild-type AmpC-producing Enterobacterales (wtAE) is frequent in intensive care unit (ICU) patients. Despite a low level of evidence, definitive antimicrobial therapy (AMT) with third generation cephalosporins (3GCs) or piperacillin is discouraged.
Methods: Observational prospective study including consecutive wtAE VAP patients in 20 French ICUs. The primary objective was to assess the association of the choice of definitive AMT, i.e. piperacillin ± tazobactam (PTZ), 3GCs or other molecule (4GCs, carbapenems, quinolones, cotrimoxazole; control group), with treatment success at day-7. Recurrence of infection was collected as a secondary outcome, and analyzed accounting for the competing risk of death.
Results: From February 2021 to June 2022, 274 patients were included. Enterobacter cloacae was the most prevalent specie (31%). Seventy-eight patients (28%) had PTZ as definitive AMT while 44 (16%) had 3GCs and 152 (56%) were classified in the control group. Day-7 success rate was similar between the 3 groups (74% vs. 73% vs. 68% respectively, p = 0.814). Recurrence probability at day-28 was 31% (95% CI 21–42), 40% (95% CI 26–55) and 21% (95% CI 15–28) for PTZ, 3GCs and control groups ( p = 0.020). In multivariable analysis, choice of definitive AMT was not associated with clinical success, but definitive AMT with 3GCs was associated with recurrence at day-28 [csHR(95%CI) 10.9 (1.92–61.91)].
Conclusion: Choice of definitive antimicrobial therapy was not associated with treatment success at day 7. However, recurrence of pneumonia at day-28 was higher in patients treated with third generation cephalosporins with no differences in mortality or mechanical ventilation duration.

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hal-04600848 , version 1 (04-06-2024)

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Matthieu Petit, Frank Bidar, Quentin Fosse, Lucie Lefevre, Marine Paul, et al.. Antibiotic definitive treatment in ventilator associated pneumonia caused by AmpC-producing Enterobacterales in critically ill patients: a prospective multicenter observational study. Critical Care, 2024, 28 (1), pp.40. ⟨10.1186/s13054-024-04820-7⟩. ⟨hal-04600848⟩
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