An antibiotic stewardship exercise in the ICU: building a treatment algorithm for the management of ventilator-associated pneumonia based on local epidemiology and the 2016 Infectious Diseases Society of America/American Thoracic Society guidelines.

INTRODUCTION: Management of ventilator-associated pneumonia (VAP), the most common infection in patients on mechanical ventilation, should be tailored to local microbiological data. The aim of this study was to determine susceptibility patterns of organisms causing VAP to develop a treatment algorithm based on these findings and evidence from the literature. MATERIALS AND METHODS: This is a retrospective analysis of the microbiological etiology of VAP in the intensive care unit (ICU) of a Lebanese tertiary care hospital from July 2015 to July 2016. We reviewed the latest clinical practice guidelines on VAP and tried to adapt these recommendations to our setting. RESULTS: In all, 43 patients with 61 VAP episodes were identified, and 75 bacterial isolates caused VAP. Extensively drug-resistant (XDR) Acinetobacter baumannii was the most common organism (37%), and it had occurred endemically throughout the year. Pseudomonas aeruginosa was the next most common organism (31%), and 13% were XDR. Enterobacteriaceae (15%) and Stenotrophomonas maltophilia (12%) shared similar incidences. Our algorithm was based on guidelines, in addition to trials, systematic reviews, and meta-analyses that studied the effectiveness of available antibiotics in treating VAP. CONCLUSION: Knowing that resistance can rapidly develop within a practice environment, more research is needed to identify the best strategy for the management of VAP.

Prescription Patterns for Tigecycline in Severely Ill Patients for Non-FDA Approved Indications in a Developing Country: A Compromised Outcome.

Introduction: With the rise in antibiotic resistance, tigecycline has been used frequently in off-label indications, based on its in-vitro activity against multidrug-resistant organisms. In this study, our aim was to assess its use in approved and unapproved indications. Materials and Methods: This is a retrospective chart review evaluating a 2-year experience of tigecycline use for > 72 h in 153 adult patients inside and outside critical care unit from January 2012 to December 2013 in a Lebanese tertiary-care hospital. Results: Tigecycline was mostly used in off-label indications (81%) and prescribed inside the critical care area, where the number of tigecycline cycles was 16/1,000 patient days. Clinical success was achieved in 43.4% of the patients. In the critically ill group, it was significantly higher in patients with a SOFA score <7 using multivariate analysis (Odds Ratio (OR) = 12.51 [4.29-36.51], P < 0.0001). Microbiological success was achieved in 43.3% of patients. Yet, the univariate and adjusted multivariate models failed to show a significant difference in this outcome between patients inside vs. outside critical care area, those with SOFA score <7 vs. ≥ 7, and in FDA-approved vs. off-label indications. Total mortality reached ~45%. It was significantly higher in critically ill patients with SOFA score ≥7 (OR = 5.17 [2.43-11.01], P < 0.0001) and in off-label indications (OR = 4.00 [1.30-12.31], P = 0.01) using an adjusted multivariate model. Gram-negative bacteria represented the majority of the clinical isolates (81%) and Acinetobacter baumannii predominated (28%). Carbapenem resistance was present in 85% of the recovered Acinetobacter, yet, more than two third of the carbapenem-resistant Acinetobacter species were still susceptible to tigecycline. Conclusion: In our series, tigecycline has been mostly used in off-label indications, specifically in severely ill patients. The outcome of such infections was not inferior to that of FDA-approved indications, especially inside critical care area. The use of this last resort antibiotic in complicated clinical scenarios with baseline microbiological epidemiology predominated by extensively-drug resistant pathogens ought to be organized.

Retrospective Analysis on the Use of Amphotericin B Lipid Complex in Neutropenic Cancer Patients with Suspected Fungal Infections in Lebanon, a Single Center Experience and Review of International Guidelines.

INTRODUCTION: Immunocompromised patients carry a high risk for invasive fungal disease (IFD), which is associated with high mortality. MATERIALS AND METHODS: This is a retrospective chart review of a 4-year experience of amphotericin B lipid complex (ABLC) utilization for the management of suspected IFD at the Hematology/Oncology and Bone Marrow Transplantation unit at Makassed General Hospital, Beirut, Lebanon between January 2011 and December 2014. We focused on treatment strategy, response rate, and adverse drug events associated with ABLC therapy. We also reviewed ABLC indications in international guidelines beyond its Food and Drug Administration approval. RESULTS: A total of 89 patients received ABLC therapy for suspected fungal infection. Forty-eight percent were treated for a possible fungal infection, 19% for a problable fungal infection, 12% based on hospital guidelines, and 20% based on treating physician's recommendations. The overall response rate was 71%. Nephrotoxicity occurred in 24% of patients and serum creatinine improved in 10% of these patients. Moderate hypokalemia was observed in 61% of the patients and severe hypokalemia in 10% but was corrected in both cases. Hepatotoxicity was observed in 12% of the patients throughout ABLC therapy. Infusion-related reactions were observed in 36% of the patients. There was a decrease in the incidence of these reactions upon using combination of premedication drugs. CONCLUSION: In this study, ABLC proved to be an effective and safe option in the management of suspected IFD in immunocompromised patients failing previous therapies.