Antibiotic treatment for nosocomial pneumonia

The management of nosocomial pneumonia has been an object of intensive investigation during the previous two decades. Up to now some important aspects have been clarified. Firstly the recognition that early and late onset pneumonia represent two separate entities with important differences in epidemiology, risk factors, and prognosis has been established. Secondly, the role of antibiotics has been re-evaluated. Today there is strong evidence that early antibiotic treatment is crucial for a favourable outcome. However, risks associated with prolonged treatment with antimicrobial agents have been recognised. Besides the increasing costs of antibiotics it is apparent that the selection of potentially drug resistant microorganisms, associated with excess mortality, is also important. Although better treatment options, like new broad spectrum antibiotics are available, antimicrobial resistance is increasing. Many studies have focused on the diagnostic and therapeutic strategies to improve the outcome. While some issues are clear others still remain controversial. Maybe the time has come to leave the individual diagnostic approach and turn to a more epidemiological point of view. Previously the American Thoracic Society (ATS) made recommendations which emphasised the following aspects: 1) initial antimicrobial therapy for hospital-acquired pneumonia (HAP) must always be empirical; 2) any antibiotic regimen must be guided by the severity of the pneumonia, the time point of the pneumonia occurrence and specific risk factors; and 3) the selection of antimicrobial agents has to consider local microbial and resistance patterns. This framework can be used as a guide for the selection of appropriate antimicrobial agents. This chapter will review the current present knowledge of antimicrobial treatment in nosocomial pneumonia. Furthermore, several issues of particular interest leading to new perspectives of antibiotic treatment will be addressed.