rocephin reduced VAP incidence

The incidence of nosocomial pneumonia in the setting of acute brain injuries is known to be high. This is most likely due to impairment of consciousness associated with global cerebral dysfunction and specific swallowing impairment due to cranial nerve dysfunction. Preventive measures have been largely unsuccessful outside of early and formalized swallowing evaluation for patients after extubation and before receiving medicines or food by mouth. A randomized, double-blind, superiority trial, PROPHY-VAP, showed that a single dose of 2 g of ceftriaxone administered in patients with brain injury who were comatose within 12 h of endotracheal intubation decreased the incidence of VAP by more than half without increased adverse events. The study also showed increased ventilator-free days, decreased mortality, and a trend toward improved functional outcome and ICU-free days.

In a 2023 multicenter, randomized controlled trial of inhaled amikacin vs placebo in a general ICU population to prevent VAP, patients receiving mechanical ventilation who received a 3-day course of the inhaled antibiotic were less likely to have VAP diagnosed by 28 days than were those who received placebo. However, several important questions remain at this time, which should be answered before inhaled amikacin is routinely adopted in practice. First, diagnosis of VAP was the primary outcome, and the study was not adequately powered to detect differences in more impactful and downstream outcomes, such as mortality and ICU length of stay. Second, the study did not identify any increased adverse events immediately related to inhaled amikacin, but whether this additional antimicrobial exposure could, over time, contribute to antimicrobial resistance remains an important question. This was not offered as a choice, but could be considered a reasonable option in the future.

Although meta-analysis of chlorhexidine baths to prevent VAP support its use, the randomized trials were not performed in patients with brain injuries, which limits our understanding of this group. Frequent suctioning has not been shown to prevent VAP. Patients with brain injury are more likely to fail spontaneous breathing trials and are often considered for early tracheostomy, but this has not been shown to reduce VAP.123

Footnotes

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  2. Dahyot-Fizelier C, Lasocki S, Kerforne T, et al; PROPHY-VAP Study Group and the ATLANREA Study Group. Ceftriaxone to prevent early ventilator-associated pneumonia in patients with acute brain injury: a multicentre, randomised, double-blind, placebo-controlled, assessor-masked superiority trial. Lancet Respir Med. 2024. PubMed ↩

  3. Klompas M. Potential strategies to prevent ventilator-associated events. Am J Respir Crit Care Med. 2015;192(12):1420-1430. PubMed ↩