Ventilator-associated pneumonia (VAP) is a severe and potentially life-threatening condition that can develop in mechanically ventilated patients for an extended period. The use of antibiotics is a standard treatment for VAP. However, the optimal duration of antibiotic therapy is still debatable, particularly concerning VAP caused by non-fermenting Gram-negative bacilli (NF-GNB).
To shed light on this issue, a team of researchers conducted a systematic review and meta-analysis of randomized controlled trials to compare the safety and efficacy of short-course (≤8 days) versus long-course (≥10–15 days) antibiotic therapy for VAP. The primary objective was to assess the rates of recurrence and relapse of VAP in patients receiving either short or long-course antibiotic therapy.
The findings of this meta-analysis, published in The Lancet, could have important implications for the treatment of VAP, particularly in patients with NF-GNB. By comparing the outcomes of patients receiving short versus long-course antibiotic therapy, the researchers aimed to determine which approach is more effective in reducing the risk of VAP recurrence and relapse. Ultimately, this could inform clinical practice and improve outcomes for patients with VAP.
Despite established guidelines for treating VAP, the optimal duration of antibiotic therapy remains a topic of debate, particularly for VAP caused by non-fermenting Gram-negative bacteria (NF-GNB). In a previous meta-analysis, a short course of antibiotic therapy effectively reduced the emergence of resistant bacteria without increasing the risk of recurrence or mortality in patients with VAP not due to NF-GNB.
However, the evidence was limited due to the focus on all types of hospital-acquired pneumonia and the inclusion of only two randomized controlled trials on patients with VAP due to NF-GNB, with one of the included RCTs being abstract.
The study found no significant difference between the two therapies regarding the recurrence and relapses of VAP, including for VAP due to NF-GNB and in the late-onset VAP subgroup. There was also no difference in mortality, ICU stay duration, mechanical ventilation duration, number of extra-pulmonary infections, and MDR emergence according to the duration of antibiotic therapy. However, short-course antibiotic therapy significantly increased the number of antibiotic-free days.
The reduced antibiotic exposure was not associated with a rise in recurrence or relapses of VAP, including for VAP caused by NF-GNB. Nonetheless, the authors advise interpreting the study results carefully, given the small sample size, lack of standardized definitions of outcomes, and other limitations. They recommend that tailored strategies should be tested in RCTs to individualize antibiotic duration treatment.
The meta-analysis showed that short-course antibiotic therapy was not inferior to long-course therapy in terms of the composite outcome of VAP recurrence and relapse. Moreover, short-course therapy was associated with significantly lower 28-day mortality, shorter mechanical ventilation duration, and shorter ICU stay length than long-course therapy. However, the number of extra-pulmonary infections was higher in the short-course group.