Journal of General Internal Medicine

, Volume 27, Issue 7, pp 845–852 | Cite as

Guideline-Based Antibiotics and Mortality in Healthcare-Associated Pneumonia

  • Karl J. Madaras-Kelly
  • Richard E. Remington
  • Kevin L. Sloan
  • Vincent S. Fan
Original Research

ABSTRACT

Background

Guidelines recommend administration of antibiotics with activity against methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa for treatment of healthcare-associated pneumonia (HCAP). It is unclear if this therapy improves outcomes for patients with HCAP.

Objective

To determine if administration of guideline-similar therapy (GST) was associated with a reduction in 30-day mortality for HCAP.

Design

Multi-center retrospective study.

Participants

Thirteen hundred and eleven admissions for HCAP in six Veterans Affairs Medical Centers.

Interventions

Each admission was classified as receiving GST, anti-MRSA or anti-pseudomonal components of GST, or other non-HCAP therapy initiated within 48 hours of hospitalization. Association between 30-day mortality and GST was estimated with a logistic regression model that included GST, propensity to receive GST, probability of recovering an organism from culture resistant to antibiotics traditionally used to treat community-acquired pneumonia (CAP-resistance), and a GST by CAP-resistance probability interaction.

Main Measures

Odds ratios and 95% confidence intervals [OR (95% CI)] of 30-day mortality for patients treated with GST and predicted probability of recovering a CAP-resistant organism, and ratio of odds ratios [ROR (95% CI)] for treatment by CAP-resistance probability interaction.

Key Results

Receipt of GST was associated with increased odds of 30-day mortality [OR = 2.11 (1.11, 4.04), P = 0.02)] as was the predicted probability of recovering a CAP-resistant organism [OR = 1.67 (1.26, 2.20), P < 0.001 for a 25% increase in probability]. An interaction between predicted probability of recovering a CAP-resistant organism and receipt of GST demonstrated lower mortality with GST at high probability of CAP resistance [ROR = 0.71(≤1.00) for a 25% increase in probability, P = 0.05].

Conclusions

For HCAP patients with high probability of CAP-resistant organisms, GST was associated with lower mortality. Consideration of the magnitude of patient-specific risk for CAP-resistant organisms should be considered when selecting HCAP therapy.

KEY WORDS

pneumonia anti-bacterial agents guideline methicillin-resistant Staphylococcus aureus Pseudomonas aeruginosa healthcare-associated infection 

Supplementary material

11606_2012_2011_MOESM1_ESM.doc (613 kb)
ESM 1(DOC 613 kb)

REFERENCES

  1. 1.
    The American Thoracic Society and the Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired. ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:388–416.CrossRefGoogle Scholar
  2. 2.
    Brito V, Niederman MS. Healthcare-associated pneumonia is a heterogeneous disease, and all patients do not need the same broad-spectrum antibiotic therapy as complex nosocomial pneumonia. Curr Opin Infect Dis. 2009;22:316–25.PubMedCrossRefGoogle Scholar
  3. 3.
    Ewig S, Welte T, Chastre J, Torres A. Rethinking the concepts of community-acquired and health-care-associated pneumonia. Lancet Infect Dis. 2010;10:279–87.PubMedCrossRefGoogle Scholar
  4. 4.
    Venditti M, Falcone M, Corrao S, Licata G, Serra P. Outcomes of patients hospitalized with community-acquired, health care-associated, and hospital-acquired pneumonia. Ann Intern Med. 2009;150:19–26.PubMedGoogle Scholar
  5. 5.
    Kett DH, Cano E, Quartin AA, et al. Implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care: an observational, multicentre cohort study. Lancet Infect Dis. 2011;11:181–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Maynard C, Chapko MK. Data resources in the Department of Veterans Affairs. Diabetes Care. 2004;27(Suppl 2):B22–6.PubMedCrossRefGoogle Scholar
  7. 7.
    Aronsky D, Haug PJ, Lagor C, Dean NC. Accuracy of administrative data for identifying patients with pneumonia. Am J Med Qual. 2005;20:319–28.PubMedCrossRefGoogle Scholar
  8. 8.
    Aronsky D, Chan KJ, Haug PJ. Evaluation of a computerized diagnostic decision support system for patients with pneumonia: study design considerations. J Am Med Inform Assoc. 2001;8:473–85.PubMedCrossRefGoogle Scholar
  9. 9.
    Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45:613–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Madaras-Kelly KJ, Remington RE, Fan VS, Sloan KL. Predicting antibiotic resistance to community-acquired pneumonia antibiotics in culture-positive patients with healthcare-associated pneumonia. J Hosp Med. 2011. doi:10.1002/jhm.942 [Epub ahead of print].
  11. 11.
    Hardin JW, Hilbe JM. Generalized Estimating Equations. Boca Raton: Chapman & Hall/CRC; 2002.CrossRefGoogle Scholar
  12. 12.
    Brookhart MA, Schneeweiss S, Rothman KJ, Glynn RJ, Avorn J, Sturmer T. Variable selection for propensity score models. Am J Epidemiol. 2006;163:1149–56.PubMedCrossRefGoogle Scholar
  13. 13.
    Højsgaard S, Halekoh U, Yan J. The R package geepack for generalized estimating equations. Journal of Statistical Software. 2006;15(2):1–11.Google Scholar
  14. 14.
    Madaras-Kelly KJ, Remington RE, Fan VS, Sloan KL. The Impact of Guideline Recommended Therapy on the Outcome of Health Care Associated Pneumonia (HCAP). 51st Annual Interscience Conference on Antimicrobial Agents and Chemotherapy. Chicago, Il.; 2011. Abstract 1453.Google Scholar
  15. 15.
    El Solh AA, Akinnusi ME, Alfarah Z, Patel A. Effect of antibiotic guidelines on outcomes of hospitalized patients with nursing home-acquired pneumonia. J Am Geriatr Soc. 2009;57:1030–5.PubMedCrossRefGoogle Scholar
  16. 16.
    Zilberberg MD, Shorr AF, Micek ST, Mody SH, Kollef MH. Antimicrobial therapy escalation and hospital mortality among patients with health-care-associated pneumonia: a single-center experience. Chest. 2008;134:963–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Carratala J, Mykietiuk A, Fernandez-Sabe N, et al. Health care-associated pneumonia requiring hospital admission: epidemiology, antibiotic therapy, and clinical outcomes. Arch Intern Med. 2007;167:1393–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Falcone M, Corrao S, Venditti M, Serra P,Licata G. Performance of PSI, CURB-65, and SCAP scores in predicting the outcome of patients with community-acquired and healthcare-associated pneumonia. Intern Emerg Med. 2011;6(5):431–6.Google Scholar
  19. 19.
    Mangino JE, Peyrani P, Ford KD, et al. Development and implementation of a performance improvement project in adult intensive care units: overview of the Improving Medicine Through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia (IMPACT-HAP) study. Crit Care. 2011;15:R38.PubMedCrossRefGoogle Scholar
  20. 20.
    Ewig S. Nosocomial pneumonia: de-escalation is what matters. Lancet Infect Dis. 2011;11:155–7.PubMedCrossRefGoogle Scholar
  21. 21.
    Yakovlev SV, Stratchounski LS, Woods GL, et al. Ertapenem versus cefepime for initial empirical treatment of pneumonia acquired in skilled-care facilities or in hospitals outside the intensive care unit. Eur J Clin Microbiol Infect Dis. 2006;25:633–41.PubMedCrossRefGoogle Scholar
  22. 22.
    Labelle AJ, Arnold H, Reichley RM, Micek ST, Kollef MH. A comparison of culture-positive and culture-negative health-care-associated pneumonia. Chest. 2010;137:1130–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Schlueter M, James C, Dominguez A, Tsu L, Seymann G. Practice patterns for antibiotic de-escalation in culture-negative healthcare-associated pneumonia. Infection. 2010;38:357–62.PubMedCrossRefGoogle Scholar
  24. 24.
    Zilberberg MD, Shorr AF. Healthcare-associated pneumonia: the state of evidence to date. Curr Opin Pulm Med. 2011;17:142–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Nseir S, Grailles G, Soury-Lavergne A, Minacori F, Alves I, Durocher A. Accuracy of American Thoracic Society/Infectious Diseases Society of America criteria in predicting infection or colonization with multidrug-resistant bacteria at intensive-care unit admission. Clin Microbiol Infect. 2010;16:902–8.PubMedGoogle Scholar
  26. 26.
    Shorr AF, Zilberberg MD, Micek ST, Kollef MH. Prediction of infection due to antibiotic-resistant bacteria by select risk factors for health care-associated pneumonia. Arch Intern Med. 2008;168:2205–10.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Karl J. Madaras-Kelly
    • 1
    • 4
  • Richard E. Remington
    • 2
    • 5
  • Kevin L. Sloan
    • 7
  • Vincent S. Fan
    • 3
    • 6
  1. 1.Clinical Pharmacy Service (119A), Veterans Affairs Medical CenterBoiseUSA
  2. 2.Research Service, Veterans Affairs Medical CenterBoiseUSA
  3. 3.Medical Service, Veterans Affairs Puget Sound Health Care SystemSeattleUSA
  4. 4.Department of Pharmacy Practice and Administrative Sciences, College of PharmacyIdaho State UniversityMeridianUSA
  5. 5.Department of Pharmacy Practice and Administrative Sciences, College of PharmacyIdaho State UniversityMeridianUSA
  6. 6.Department of Pulmonary and Critical Care MedicineUniversity of Washington School of MedicineSeattleUSA
  7. 7.Private PracticeSeattleUSA

Personalised recommendations