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-KellyEmail author
  • Richard E. Remington
  • Kevin L. Sloan
  • Vincent S. Fan
Original Research



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.


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


Multi-center retrospective study.


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


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].


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.


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



This study was supported through a grant from the National Institute of Allergy and Infectious Diseases (RO3AI074894-01A2). This work was supported in part with resources of the Boise and Puget Sound Health Care System Veterans Affairs Medical Centers.

This work was presented in part at the 51st Annual Interscience Conference on Antimicrobial Agents and Chemotherapy. Chicago, Il.; September 19th, 2011, Abstract # 1453.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

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


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Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Karl J. Madaras-Kelly
    • 1
    • 4
    Email author
  • 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

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