Articles
Implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care: an observational, multicentre cohort study

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Summary

Background

The American Thoracic Society and Infectious Diseases Society of America provide guidelines for management of hospital-acquired, ventilator-associated, and health-care-associated pneumonias, consisting of empirical antibiotic regimens for patients at risk for multidrug-resistant pathogens. We aimed to improve compliance with these guidelines and assess outcomes.

Methods

We implemented a performance-improvement initiative in four academic medical centres in the USA with protocol-based education and prospective observation of outcomes. Patients were assessed for severity of illness and followed up until death, hospital discharge, or day 28. We included patients in intensive-care units who were at risk for multidrug-resistant pneumonia and were treated empirically.

Findings

303 patients at risk for multidrug-resistant pneumonia were treated empirically, and prescribed treatment was guideline compliant in 129 patients and non-compliant in 174 patients. 44 (34%) patients died before 28 days in the compliance group and 35 (20%) died in the non-compliance group. Five patients in the compliance group and seven in the non-compliance group were lost to follow-up after day 14. Kaplan-Meier estimated survival to 28 days was 65% in the compliance group and 79% in the non-compliance group (p=0·0042). This difference persisted after adjustment for severity of illness. Median length of stay and duration of mechanical ventilation did not differ between groups. Compliance failures included non-use of dual treatment for Gram-negative pathogens in 154 patients and absence of meticillin-resistant Staphylococcus aureus coverage in 24 patients. For patients in whom pathogens were subsequently identified, empirical treatment was active in 79 (81%) of 97 of patients receiving compliant therapy compared with 109 (85%) of 128 of patients receiving non-compliant therapy.

Interpretation

Because adherence with empirical treatment was associated with increased mortality, we recommend a randomised trial be done before further implementation of these guidelines.

Funding

Pfizer, US Medical.

Introduction

Hospital-acquired pneumonia is one of the most common nosocomial infections. Its high morbidity and mortality and associated long and costly hospital stays have been attributed in part to delayed use of effective antibiotics because of increasing antimicrobial resistance.1, 2, 3, 4, 5, 6, 7, 8, 9 Culture-guided corrections to initially inadequate antimicrobial treatment strategies do not reduce death rates,8, 10, 11, 12 and prompt treatment of hospital-acquired pneumonia with broad-spectrum empirical antibiotics is therefore recommended.13

The American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) published updated guidelines13 for treatment of hospital-acquired pneumonia and related infections in 2005. In these guidelines, the choice of empirical treatment is determined by whether patients have recognised risk factors for multidrug-resistant pathogens. Patients at risk include not only those with late-onset ventilator-associated pneumonia and hospital-acquired pneumonia, but also those with other health-care-associated pneumonias. This group includes patients who have been in hospital for 2 days or more in the preceding 90 days; reside in a nursing home or extended-care facility; receive chronic dialysis, home infusion therapy, or home wound care; have a family member infected with a multidrug-resistant organism or live in a community with a high prevalence of antibiotic resistance; recently received systemic antibiotics; or have an immunosuppressive disease or receive immunosuppression therapy.13

For patients at risk of infection with a multidrug-resistant pathogen, the guidelines13 recommend empirical treatment with the following drugs: an antipseudomonal cephalosporin, carbapenem, or β-lactam and β-lactamase inhibitor; an aminoglycoside or antipseudomonal fluoroquinolone; and linezolid or vancomycin. These guidelines support the development of protocols for initial empirical antibiotic therapy to increase the likelihood of adequate coverage14, 15, 16, 17, 18 and suggest antibiotic selection should be tailored to local patterns of susceptibility.

The ATS and IDSA explicitly recognise the need for guideline validation. As part of this validation, we created an initiative to improve performance in intensive-care units called Improving Medicine through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia (IMPACT-HAP). We aimed to assess the relation between guideline compliance and outcomes for patients in intensive care with multidrug-resistant pneumonia.

Section snippets

Patients

IMPACT-HAP was a multicentre initiative aimed at improving the care for patients with pneumonia in an intensive-care unit implemented in four academic medical centres in the USA: University of Louisville Medical Center (Louisville, KY), the Ohio State University Medical Center (Columbus, OH), Henry Ford Health System (Detroit, MI), and the University of Miami and Jackson Memorial Hospital (Miami, FL).

Adult patients (≥18 years of age) in participating intensive-care units were eligible for

Results

413 patients with pneumonia were in the IMPACT-HAP database. 303 had risk factors for multidrug-resistant pneumonia and were eligible for this analysis, and most required mechanical ventilation during their disease course (figure 1). All patients satisfying criteria for health-care-associated pneumonia also satisfied criteria for hospital-acquired pneumonia. 129 patients received guideline-compliant13 empirical antibiotic treatment, whereas 174 patients received non-compliant treatment. Reasons

Discussion

In our cohort study, compliance with the ATS–IDSA guidelines13 was associated with increased mortality.

Present recommendations13 for management of pneumonia in patients at risk for multidrug-resistant pathogens call for prompt broad-spectrum empirical treatment. This recommendation is supported by the consistent finding that delaying of effective antibiotic therapy is associated with increased mortality.5, 8, 10 The ATS–IDSA guidelines recommend that patients at risk should initially receive a

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