{"markup":"\u003C?xml version=\u00221.0\u0022 encoding=\u0022UTF-8\u0022 ?\u003E\n    \u003Chtml version=\u0022HTML+RDFa+MathML 1.1\u0022\n    xmlns:content=\u0022http:\/\/purl.org\/rss\/1.0\/modules\/content\/\u0022\n    xmlns:dc=\u0022http:\/\/purl.org\/dc\/terms\/\u0022\n    xmlns:foaf=\u0022http:\/\/xmlns.com\/foaf\/0.1\/\u0022\n    xmlns:og=\u0022http:\/\/ogp.me\/ns#\u0022\n    xmlns:rdfs=\u0022http:\/\/www.w3.org\/2000\/01\/rdf-schema#\u0022\n    xmlns:sioc=\u0022http:\/\/rdfs.org\/sioc\/ns#\u0022\n    xmlns:sioct=\u0022http:\/\/rdfs.org\/sioc\/types#\u0022\n    xmlns:skos=\u0022http:\/\/www.w3.org\/2004\/02\/skos\/core#\u0022\n    xmlns:xsd=\u0022http:\/\/www.w3.org\/2001\/XMLSchema#\u0022\n    xmlns:mml=\u0022http:\/\/www.w3.org\/1998\/Math\/MathML\u0022\u003E\n  \u003Chead\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_itu2PgFdrjV-docKmLK8Jn5oXe_05RgvQh73eOhI_mE.js\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_at_symbol.js?nzny02\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_article_reference_popup.js?nzny02\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_I8yX6RYPZb7AtMcDUA3QKDZqVkvEn35ED11_1i7vVpc.js\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\n(function(i,s,o,g,r,a,m){i[\u0022GoogleAnalyticsObject\u0022]=r;i[r]=i[r]||function(){(i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o),m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m)})(window,document,\u0022script\u0022,\u0022\/\/www.google-analytics.com\/analytics.js\u0022,\u0022ga\u0022);ga(\u0022create\u0022, \u0022UA-15605596-27\u0022, {\u0022cookieDomain\u0022:\u0022auto\u0022});ga(\u0022set\u0022, \u0022page\u0022, location.pathname + location.search + location.hash);ga(\u0022send\u0022, \u0022pageview\u0022);ga(\u0027create\u0027, \u0027UA-189672-26\u0027, \u0027auto\u0027, {\u0027name\u0027: \u0027hwTracker\u0027});\r\nga(\u0027hwTracker.send\u0027, \u0027pageview\u0027);\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\njQuery.extend(Drupal.settings, {\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;13\\\/4\\\/26\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;13\\\/4\\\/26\u0022}],\u0022ac\u0022:{\u0022spmdc;13\\\/4\\\/26\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;13\\\/4\\\/26\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003ENosocomial pneumonia, especially ventilator-associated pneumonia (VAP), is a major cause of morbidity and mortality in the intensive care unit (ICU). This article discusses updates on bacterial resistance relevant to VAP, with a focus on methicillin-resistant \u003Cem\u003EStaphylococcus aureus\u003C\/em\u003E (MRSA), treating MRSA pneumonia in the ICU, the use of tigecycline and doripenem for hospital-acquired pneumonia and VAP, and the potential utility of inhaled antibiotics as an alternative in the treatment of patients with VAP.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ENursing\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EBacterial Infections\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPneumonia\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EDrug Resistance\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ENursing\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EBacterial Infections\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPneumonia\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPulmonary \u0026amp; Critical Care\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EDrug Resistance\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003ENosocomial pneumonia, especially ventilator-associated pneumonia (VAP), is a major cause of morbidity and mortality in the intensive care unit (ICU).\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EMark L. Metersky, MD, University of Connecticut School of Medicine, Farmington, Connecticut, USA, provided an update on bacterial resistance relevant to VAP, with a focus on methicillin-resistant \u003Cem\u003EStaphylococcus aureus\u003C\/em\u003E (MRSA). Vancomycin-resistant \u003Cem\u003ES. aureus\u003C\/em\u003E is rare (limited to case reports) but the prevalence of vancomycin-intermediate \u003Cem\u003ES. aureus\u003C\/em\u003E (VISA) is probably increasing. Heteroresistant VISA (hVISA) is challenging to detect; using population analysis profiling area under the curve (AUC) as a reference method, the hVISA phenotype can be detected for strains of \u003Cem\u003ES. aureus\u003C\/em\u003E with vancomycin minimum inhibitory concentration (MIC) levels as low as 0.5 \u03bcg\/mL [Howden BP et al. \u003Cem\u003EClin Microbiol Rev\u003C\/em\u003E 2010; Musta AC et al. \u003Cem\u003EJ Clin Microbiol\u003C\/em\u003E 2009].\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EVancomycin MIC \u201ccreep\u201d refers to an increase in the frequency of MICs approaching 2 \u03bcg\/mL, considered to be the cutoff for vancomycin sensitivity. The significance of the MIC creep is not clear, as studies assessing the impact of vancomycin treatment on response have produced variable results. Regional variation in the contribution of MRSA to \u003Cem\u003ES. aureus\u003C\/em\u003E VAP is marked. In the United States and Europe, the prevalence of MRSA seems to have stabilized, although at various levels depending upon the country studied.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EGram-negative resistance in VAP continues to increase, but like MRSA, the prevalence across the world varies widely. For example, \u003Cem\u003EAcinetobacter sp.\u003C\/em\u003E cause approximately 5% of VAP in the United States [Jones RN. \u003Cem\u003EClin Infect Dis\u003C\/em\u003E 2010] and \u223c35% in Asia)[Chung DR et al. \u003Cem\u003EAm J Respir Crit Care\u003C\/em\u003E 2011]. This organism is typically multi-drug resistant. \u003Cem\u003EKlebsiella pneumoniae\u003C\/em\u003E is a Gram-negative organism that is increasingly resistant to carbapenems; several other Gram-negative \u003Cem\u003EEnterobacteriaceae\u003C\/em\u003E and non-\u003Cem\u003EEnterobacteriaceae\u003C\/em\u003E also produce carbapenemases. \u003Cem\u003EIn vitro\u003C\/em\u003E ertapenem resistance suggests \u003Cem\u003EK. pneumoniae\u003C\/em\u003E carbapenemase with resulting imipenem and meropenem resistance despite \u003Cem\u003Ein vitro\u003C\/em\u003E susceptibility, said Dr. Metersky.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EAntibiotic stewardship is necessary to help limit the development of resistant strains in the hospital. The elements of stewardship include treating infection and not treating colonization, determining the infecting organism, initial appropriate antibiotic therapy at a sufficient dose, deescalation, and avoiding excessive length of therapy.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EMichael S. Niederman, MD, Winthrop University Hospital, Mineola, New York, USA, discussed treating MRSA pneumonia in the ICU, noting that resistance is a risk factor for mortality. Even with appropriate therapy with vancomycin, mortality for those with MRSA VAP was 48% in one series of 75 cases, which was double the risk of mortality compared with controls [Rello J et al. \u003Cem\u003ECrit Care Med\u003C\/em\u003E 2005]. In a subset of patients who received continuous-infusion vancomycin, however, the mortality rate declined to half compared with those treated with intermittent vancomycin, which suggests that attributable mortality of MRSA VAP could be lowered with better therapies. Other studies show longer length of stay [Shorr AF et al. \u003Cem\u003ECrit Care Med\u003C\/em\u003E 2006] and slower resolution of MRSA VAP than other forms of pneumonia, despite appropriate treatment (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Vidaur L et al. \u003Cem\u003EChest\u003C\/em\u003E 2008].\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003ECombination therapy is needed to optimize treatment of Gram-negative bacteria in VAP, and usually requires a \u03b2-lactam antibiotic with an aminoglycoside. In 2013, MRSA must be considered when selecting therapy in virtually every patient on a ventilator who develops nosocomial pneumonia, said Dr. Niederman. With rising MIC levels for vancomycin, optimizing drug dosing is essential, although even optimization may not lead to good outcomes if the vancomycin MIC is \u0026gt;1 \u03bcg\/mL, and aggressive vancomycin dosing may promote nephrotoxicity [Lodise TP et al. \u003Cem\u003EClin Infect Dis\u003C\/em\u003E 2009].\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EFor proven MRSA VAP, linezolid may offer advantages over optimally dosed vancomycin. In a head-to-head, randomized, double-blind comparison, clinical response at end of study was significantly higher with linezolid than with vancomycin dosed optimally in the treatment of documented MRSA nosocomial pneumonia [Wunderink RG et al. \u003Cem\u003EClin Infect Dis\u003C\/em\u003E 2012] although 30-day mortality was not different between the two treatment groups (\u223c15% in each group). One factor that may have prevented detection of a difference in mortality was that clinical failures with vancomycin were allowed salvage therapy with linezolid.\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/4\/26\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022MRSA VAP Is Slow to Clinically Resolve\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-657542944\u0022 data-figure-caption=\u0022MRSA VAP Is Slow to Clinically Resolve\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/4\/26\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/4\/26\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/4\/26\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13115\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-10\u0022 class=\u0022first-child\u0022\u003EMRSA VAP Is Slow to Clinically Resolve\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EMRSA=methicillin-resistant \u003Cem\u003EStaphylococcus aureus\u003C\/em\u003E; MSSA=methicillin-sensitive \u003Cem\u003EStaphylococcus aureus\u003C\/em\u003E; VAP=ventilator-associated pneumonia.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from Vidaur L et al. Ventilator-Associated Pneumonia: Impact of Organisms on Clinical Resolution and Medical Resources Utilization. \u003Cem\u003EChest\u003C\/em\u003E 2008;133(3):625. With permission from Elsevier.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-11\u0022\u003ERichard Wunderink, MD, Northwestern University, Chicago, Illinois, USA, reviewed data from recent trials of tigecycline and doripenem for hospital-acquired pneumonia (HAP) and VAP. In a randomized comparison of tigecycline and imipenem\/cilastatin for the treatment of HAP, the clinical response rate was markedly superior with imipenem in a subset with VAP (47.9% vs 70.1%) and in those with MRSA (40.0% vs 81.8%), \u003Cem\u003EAcinetobacter\u003C\/em\u003E spp (57.1% vs 94.7%), or \u003Cem\u003EPseudomonas aeruginosa\u003C\/em\u003E (27.3% vs 85.7%) infection [Freire AT et al. \u003Cem\u003EDiagn Microbiol Infect Dis\u003C\/em\u003E 2010].\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EIn a randomized trial of 7 days of doripenem versus 10 days of imipenem\/cilastatin in patients with VAP, the overall clinical cure rate was better with imipenem\/cilastatin (56.8%) than with doripenem (45.6%; \u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Kollef MH et al. \u003Cem\u003ECrit Care\u003C\/em\u003E 2012]. Inadequate dosing of tigecycline as determined by the \u003Cem\u003Ef\u003C\/em\u003EAUC\u003Csub\u003E0\u201324\u003C\/sub\u003E:MIC ratio appears to be responsible for lower clinical and microbiologic responses in VAP patients [Bhavnani SM et al. \u003Cem\u003EAntimicrob Agents Chemother\u003C\/em\u003E 2012]. One lesson is that the pharmacokinetic\/pharmacodynamics characteristics in some critically ill patients are different, including an increased creatinine clearance.\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EIn both of the aforementioned studies, the mortality rate was lower with imipenem\/cilastatin but differences did not emerge until after the study drugs were stopped. These data suggest that VAP does have an attributable mortality that tracks with the more subjective clinical response, doesn\u0027t usually occur during the time of VAP treatment, and is only revealed when no salvage therapy is available.\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EIn patients with difficult to treat pathogens, minimum bactericidal concentrations may be more relevant than MIC in determining an adequate dose and duration of treatment, said Dr. Wunderink. In some cases, a loading dose may be needed when prolonged infusions are chosen.\u003C\/p\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/4\/26\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Clinical Response in Carbapenem VAP Trial\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-657542944\u0022 data-figure-caption=\u0022Clinical Response in Carbapenem VAP Trial\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/4\/26\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/4\/26\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/4\/26\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13117\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-15\u0022 class=\u0022first-child\u0022\u003EClinical Response in Carbapenem VAP Trial\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-16\u0022\u003EAntonio Anzueto, MD, University of Texas Health Science Center, San Antonio, Texas, USA, discussed the potential utility of inhaled antibiotics as an alternative in the treatment of patients with VAP. Nebulized antibiotics provide higher pulmonary concentrations than intravenous (IV) administration at the same dose, and are influenced by lung aeration [Elman M et al. \u003Cem\u003EAnesthesiology\u003C\/em\u003E 2002]. Aerosolized antibiotics reduced signs of respiratory infection and the bacterial burden in tracheal aspirates in critically ill intubated patients [Palmer LB et al. \u003Cem\u003ECrit Care Med\u003C\/em\u003E 2008].\u003C\/p\u003E\u003Cp id=\u0022p-17\u0022\u003EPulmonary delivery of aerosolized amikacin exceeded the MIC levels in the alveolar epithelial lining fluid for Gram-negative microorganisms usually responsible for VAP [Luyt CE et al. \u003Cem\u003ECrit Care\u003C\/em\u003E 2009].\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003EIn a Phase 2 trial, nebulized ceftazidime and amikacin had similar success as IV administration in the treatment of patients with \u003Cem\u003EP. aeruginosa\u003C\/em\u003E VAP (n=40), and acquisition of per-treatment antibiotic resistance was observed only in the IV group [Lu Q et al. \u003Cem\u003EAm J Respir Crit Care Med\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cp id=\u0022p-19\u0022\u003EAn investigational delivery system for amikacin achieved tracheal aspirate amikacin maximum concentration and a ratio of area under the aspirate concentration-time curve in 50% of patients with dosing every 12 hours in a Phase 2 randomized, placebo-controlled study of 69 mechanically ventilated patients with Gram-negative pneumonia [Niederman MS et al. \u003Cem\u003EIntensive Care Med\u003C\/em\u003E 2012], and warrants further clinical evaluation.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/13\/4\/26.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzny02\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzny02\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}