Double-coverage for VAP

PulmCrit (EMCrit)

The siren’s call: Double-coverage for ventilator associated PNA

PulmCrit - August 29, 2016 - By Josh Farkas 

• "Prospective RCTs have not shown a benefit from double-coverage.
• In order for double-coverage to be beneficial, a chain of events must occur. The patient must truly have VAP, that VAP must be due to a gram-negative, the gram negative must be resistant to the beta-lactam, the gram negative must be sensitive to the second antibiotic, and broader antibiotic coverage must make a clinical difference. The likelihood of this entire sequence of events occurring is about 1-2%.
• Double-coverage with a fluoroquinolone is difficult to justify given rising resistance to fluoroquinolones and a significant toxicity profile.
• Double-coverage with an aminoglycoside may be considered in specific patients, but in most cases nephrotoxicity outweighs benefit.
• Monotherapy with an optimal beta-lactam may be more effective than double-coverage with a suboptimal beta-lactam. More isn’t necessarily better.
• The IDSA recommendation utilize double-coverage in nearly all patients with VAP is not evidence-based."