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El énfasis en el manejo de la neumonía nosocomial está actualmente centrado en la efectividad del tratamiento antibiótico y su efecto en la mortalidad. Alrededor del 62% de los pacientes con neumonía asociada a ventilación mecánica (NAV) cumple al menos un criterio objetivo de fallo terapéutico. Los microorganismos predominantes asociados con fallo terapéutico son Pseudomonas aeruginosa y Staphylococcus aureus resistente a meticilina. Hay múltiples causas de fallo de resolución en NAV: inmunocompromiso, resistencia antibiótica oculta, dosificación inadecuada, sobreinfecciones concomitantes o posteriores. El diagnóstico de fallo antibiótico y la distinción entre sobreinfección o causas no infecciosas es difícil porque los criterios clínicos aislados son inadecuados. La respuesta microbiológica es valorable sólo si se emplean cultivos cuantitativos. Los marcadores bioquímicos pueden ser más precisos que los clínicos, pero todavía no discriminan entre causas. La estrategia diagnóstica adecuada y los algoritmos terapéuticos están en discusión y se precisa mayor investigación en este campo.
Palabras clave:
Neumonía
Antibióticos
Resistencia
Emphasis in VAP management is now shifting to the effectiveness of antibiotic therapy and its effect on subsequent mortality. As many as 62% of patients with VAP meet a set of objective criteria for failure to respond. The predominant microorganisms associated with failure of therapy are Pseudomonas aeruginosa and methicillin-resistant S. aureus (MRSA). Multiple causes of failure to respond in VAP exist: compromised host immunity, occult antibiotic resistance, inadequate antibiotic dosing, and concomitant or subsequent superinfections. The diagnosis of antibiotic failure and distinguishing failure from superinfection or noninfectious mimics is difficult because clinical criteria alone are inadequate. Microbiologic response is accurate only if quantitative cultures are used. Biochemical markers may be more accurate than clinical but still don’t discriminate between causes. The appropriate diagnostic strategy and treatment algorithms have not been fully addressed and more research is clearly needed.
Key words:
Pneumonia
Antibiotics
Resistance
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