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A Randomized Trial

Jean Chastre, MD; Michel Wolff, MD; Jean-Yves Fagon, MD; Sylvie Chevret, MD; Franck Thomas, MD; Delphine Wermert, MD; Eva Clementi, MD; Jesus Gonzalez, MD; Dominique Jusserand, MD; Pierre Asfar, MD; Dominique Perrin, MD; Fabienne Fieux, MD; Sylvie Aubas, MD; for the PneumA Trial Group

JAMA. 2003;290:2588-2598.

Context  The optimal duration of antimicrobial treatment for ventilator-associated pneumonia (VAP) is unknown. Shortening the length of treatment may help to contain the emergence of multiresistant bacteria in the intensive care unit (ICU).

Objective  To determine whether 8 days is as effective as 15 days of antibiotic treatment of patients with microbiologically proven VAP.

Design, Setting, and Participants  Prospective, randomized, double-blind (until day 8) clinical trial conducted in 51 French ICUs. A total of 401 patients diagnosed as having developed VAP by quantitative culture results of bronchoscopic specimens and who had received initial appropriate empirical antimicrobial therapy were enrolled between May 1999 and June 2002.

Intervention  A total of 197 patients were randomly assigned to receive 8 days and 204 to receive 15 days of therapy with an antibiotic regimen selected by the treating physician.

Main Outcome Measures  Primary outcome measures—death from any cause, microbiologically documented pulmonary infection recurrence, and antibiotic-free days—were assessed 28 days after VAP onset and analyzed on an intent-to-treat basis.

Results  Compared with patients treated for 15 days, those treated for 8 days had neither excess mortality (18.8% vs 17.2%; difference, 1.6%; 90% confidence interval [CI], -3.7% to 6.9%) nor more recurrent infections (28.9% vs 26.0%; difference, 2.9%; 90% CI, -3.2% to 9.1%), but they had more mean (SD) antibiotic-free days (13.1 [7.4] vs 8.7 [5.2] days, P<.001). The number of mechanical ventilation–free days, the number of organ failure–free days, the length of ICU stay, and mortality rates on day 60 for the 2 groups did not differ. Although patients with VAP caused by nonfermenting gram-negative bacilli, including Pseudomonas aeruginosa, did not have more unfavorable outcomes when antimicrobial therapy lasted only 8 days, they did have a higher pulmonary infection-recurrence rate compared with those receiving 15 days of treatment (40.6% vs 25.4%; difference, 15.2%, 90% CI, 3.9%-26.6%). Among patients who developed recurrent infections, multiresistant pathogens emerged less frequently in those who had received 8 days of antibiotics (42.1% vs 62.0% of pulmonary recurrences, P = .04).

Conclusions  Among patients who had received appropriate initial empirical therapy, with the possible exception of those developing nonfermenting gram-negative bacillus infections, comparable clinical effectiveness against VAP was obtained with the 8- and 15-day treatment regimens. The 8-day group had less antibiotic use.

Author Affiliations: Service de Réanimation Médicale, Hôpital Pitié-Salpêtrière, AP-HP (Dr Chastre), Service de Réanimation Médicale, Hôpital Bichat-Claude-Bernard, AP-HP (Dr Wolff), Service de Réanimation Médicale, Hôpital Européen Georges-Pompidou, AP-HP (Dr Fagon), Département de Biostatistique et Informatique Médicale, Hôpital Saint-Louis, AP-HP (Dr Chevret), and Service de Réanimation, Hôpital des Diaconesses, Paris (Dr Thomas); Service de Réanimation Médicale, Hôpital Kremlin-Bicêtre, AP-HP, Le Kremlin-Bicêtre (Dr Wermert); Service de Réanimation, Hôpital Les Audaries, La-Roche-sur-Yon (Dr Clementi); Service de Réanimation Médicale, Hôpital Raymond-Poincaré, AP-HP, Garches (Dr Gonzalez); Département d'Anesthésie et de Réanimation, CHU de Rouen, Rouen (Dr Jusserand); Service de Réanimation Médicale, CHU d'Angers, Angers (Dr Asfar); Service de Réanimation, Hôpital Courcouronne, Évry (Dr Perrin); Service de Réanimation Médicale, Hôpital Saint-Louis, AP-HP, Paris (Dr Fieux); and Département d'Anesthésie et de Réanimation, CHU de Montpellier, Montpellier (Dr Aubas), France.

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