Impact of Clinical Guidelines in the Management of Severe Hospital-Acquired Pneumonia

doi:10.1378/chest.128.4.2778

Chest

Volume 128, Issue 4, October 2005, Pages 2778-2787

https://doi.org/10.1378/chest.128.4.2778 Get rights and content

Study objectives

To asses the impact of locally developed antimicrobial treatment guidelines in the initial empiric treatment of ICU patients with severe hospital-acquired pneumonia (HAP).

Design

Observational cohort study with preguideline and postguideline data collection.

Patients

A total of 48 preguideline patients with 56 episodes of severe HAP defined by the National Nosocomial Infections Surveillance (NNIS) compared with 58 guideline-treated (GUIDE) patients with 61 episodes of severe HAP.

Results

The two groups were similar in terms of mean (± SD) age (NNIS group, 67.7 ± 9.6 years; GUIDE group, 68.0 ± 11.5 years) and simplified acute physiology score (NNIS group, 12.9 ± 3.9; GUIDE group, 12.6 ± 3.1) at the HAP diagnosis, and the proportion of the most frequent isolates (ie, Pseudomonas and methicillin-resistant Staphylococcus aureus). There was wide variation in initial antibiotic use in NNIS-treated patients, with cefotaxime, ceftazidime, and piperacillin being the most common agents compared with all of the GUIDE patients who received an imipenem-cilastin-based regimen. Vancomycin use was similar in both groups. The GUIDE patients had a higher percentage of adequately treated patients (81% vs 46%, respectively; p < 0.01) with a lower mortality rate at 14 days (8% vs 23%, respectively; p = 0.03). A lower mortality rate was also noted at the end of 30 days and the end of hospitalization but was not statistically significant. Appropriate imipenem use (as defined by the guidelines) occurred in 74% of the cases, and there was no increase in the number of imipenem-resistant organisms isolated during the course of the study.

Conclusions

These guidelines represent a successful implementation of a “deescalation” approach, because the recommended empiric therapy with broad-spectrum antibiotics was switched to therapy with narrower spectrum agents after 3 days. Based on our experience, this approach improves the adequacy of antibiotic treatment, with improvement in short-term survival and without increasing the emergence of resistant organisms.

Section snippets

Materials and Methods

The West Los Angeles Healthcare Center is a tertiary care facility with > 200 medical-surgical beds, of which 25 are ICU beds. No specific local guidelines for the treatment of pneumonia were in place prior to 1999. The management of patients with pneumonia (community-acquired pneumonia or HAP) was at the discretion of the physician staff. Perhaps reflecting the fact that national guidelines or consensus statements for the management of pneumonia provide only general recommendations regarding

Results

There were 48 patients in the NNIS database with 56 episodes of HAP, and they were designated as the NNIS group. All of the patients had been treated prior to guideline implementation. Fifty-eight patients with 61 episodes of HAP were treated according to the guidelines and comprised the GUIDE group. Basic demographics are summarized in Table 1. In those patients with more than one episode of HAP in the NNIS group, the episodes of HAP occurred a least 1 month apart during the same

Discussion

Of the many factors that influence the outcome of patients with VAP, the timely administration of effective antimicrobial therapy, well before culture results are known, forms the cornerstone for successful therapy.²⁶²⁷ The choice of appropriate therapy has a dramatic effect, with the mortality rate reduced by as much as one half to two thirds of that seen with inadequate antibiotic coverage.

Guidelines can help to facilitate appropriate management, and there has been an explosion in the number

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2021, Archives de Pediatrie
Carbapenems, last-resort antibiotics, are widely used as first-line treatment in patients carrying extended-spectrum beta-lactamases (ESBL) Enterobacteriaceae, including in a pediatric setting. We aimed to implement an antibiotic stewardship program (ASP) to improve the use of carbapenems.
We implemented an ASP at the Bordeaux Children's University Hospital with 6-month audits on prescribing practice before and after an intervention (revision of antibiotic treatment protocols, a half-day educational session with feedback of the first study period). The number of carbapenem prescriptions was analyzed and two criteria were used to assess conformity of the indication for carbapenem prescription and conformity of the reassessment. A logistic regression was used to assess the overall compliance of carbapenem prescriptions over the two periods adjusted for ESBL carriage.
A total of 57 patients were included with 37 carbapenem prescriptions before the intervention and 23 after. Overall carbapenem consumption decreased from 0.54 prescriptions per 100 admissions to 0.32 (p = 0.06). Conformity increased during the study for indication (46–87%, p = 0.004) and for reassessment (48–78%, p = 0.04) and was significantly associated with the second study period, after adjustment for ESBL carriage.
Our intervention contributed to a significant improvement in the compliance to indications for carbapenem indication and in the reassessment of the prescription.
Antibiotic de-escalation for bloodstream infections and pneumonia: systematic review and meta-analysis
2016, Clinical Microbiology and Infection
Antibiotic de-escalation is an appealing strategy in antibiotic stewardship programmes. We aimed to assess its safety and effects using a systematic review and meta-analysis. We included randomized controlled trials (RCTs) and observational studies assessing adults with bacteraemia, microbiologically documented pneumonia or severe sepsis, comparing between antibiotic de-escalation and no de-escalation. De-escalation was defined as changing an initially covering antibiotic regimen to a narrower spectrum regimen based on antibiotic susceptibility testing results within 96 hours. The primary outcome was 30-day all-cause mortality. A search of published articles and conference proceedings was last updated in September 2015. Crude and adjusted ORs with 95% CI were pooled in random-effects meta-analyses. Sixteen observational studies and three RCTs were included. Risk of bias related to confounding was high in the observational studies. De-escalation was associated with fewer deaths in the unadjusted analysis (OR 0.53, 95% CI 0.39–0.73), 19 studies, moderate heterogeneity. In the adjusted analysis there was no significant difference in mortality (adjusted OR 0.83, 95% CI 0.59–1.16), 11 studies, moderate heterogeneity and the RCTs showed non-significant increased mortality with de-escalation (OR 1.73, 95% 0.97–3.06), three trials, no heterogeneity. There was a significant unadjusted association between de-escalation and survival in bacteraemia/severe sepsis (OR 0.45, 95% CI 0.30–0.67) and ventilator-associated pneumonia (OR 0.49, 95% CI 0.26–0.95), but not with other pneumonia (OR 0.97, 95% CI 0.45–2.12). Only two studies reported on the emergence of resistance with inconsistent findings. Observational studies suggest lower mortality with antibiotic susceptibility testing-based de-escalation for bacteraemia, severe sepsis and ventilator-associated pneumonia that was not demonstrated in RCTs.
Adherence to antibiotic treatment guidelines and outcomes in the hospitalized elderly with different types of pneumonia
2015, European Journal of Internal Medicine
Few studies evaluated the clinical outcomes of Community Acquired Pneumonia (CAP), Hospital-Acquired Pneumonia (HAP) and Health Care-Associated Pneumonia (HCAP) in relation to the adherence of antibiotic treatment to the guidelines of the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) in hospitalized elderly people (65 years or older).
Data were obtained from REPOSI, a prospective registry held in 87 Italian internal medicine and geriatric wards. Patients with a diagnosis of pneumonia (ICD-9 480-487) or prescribed with an antibiotic for pneumonia as indication were selected. The empirical antibiotic regimen was defined to be adherent to guidelines if concordant with the treatment regimens recommended by IDSA/ATS for CAP, HAP, and HCAP. Outcomes were assessed by logistic regression models.
A diagnosis of pneumonia was made in 317 patients. Only 38.8% of them received an empirical antibiotic regimen that was adherent to guidelines. However, no significant association was found between adherence to guidelines and outcomes. Having HAP, older age, and higher CIRS severity index were the main factors associated with in-hospital mortality.
The adherence to antibiotic treatment guidelines was poor, particularly for HAP and HCAP, suggesting the need for more adherence to the optimal management of antibiotics in the elderly with pneumonia.
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2015, Journal of Infection
Bacterial resistance has become a major public health problem.
To validate the definition of multidrug-resistant organisms (MDRO) based on the European Centre for Disease Prevention and Control (ECDC) and the Centers for Disease Control and Prevention (CDC) classification.
Prospective, observational study in six medical and surgical Intensive-Care-Units (ICU) of a University hospital.
Three-hundred-and-forty-three patients with ICU-acquired pneumonia (ICUAP) were prospectively enrolled, 140 patients had no microbiological confirmation (41%), 82 patients (24%) developed ICUAP for non-MDRO, whereas 121 (35%) were MDROs. Non-MDRO, MDRO and no microbiological confirmation patients did not present either a significant different previous antibiotic use (p 0.18) or previous hospital admission (p 0.17). Appropriate antibiotic therapy was associated with better ICU survival (105 [92.9%] vs. 74 [82.2%]; p = 0.03). An adjusted multivariate regression logistic analysis identified that only MDRO had a higher ICU-mortality than non-MDRO and no microbiological confirmation patients (OR 2.89; p < 0.05; 95% CI for Exp [β]. 1.02–8.21); Patients with MDRO ICUAP remained in ICU for a longer period than MDRO and no microbiological confirmation respectively (p < 0.01) however no microbiological confirmation patients had more often antibiotic consumption than culture positive ones.
Patients who developed ICUAP due to MDRO showed a higher ICU-mortality than non-MDRO ones and use of ICU resources. No microbiological confirmation patients had more often antibiotic consumption than culture positive patients. Risk factors for MDRO may be important for the selection of initial antimicrobial therapy, in addition to local epidemiology.
Strategies to reduce curative antibiotics use in the intensive care units (adult and pediatric) - Guidelines and expert panel report
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Early Discontinuation of Antibiotics in Patients Admitted With Clinically Suspected Serious Infection but Negative Cultures: Retrospective Cohort Study of Practice Patterns and Outcomes at 111â US Hospitals
2023, Open Forum Infectious Diseases

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Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

This study was supported in part by a grant from Merck & Co, Inc.

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Chest

Clinical Investigations in Critical CareImpact of Clinical Guidelines in the Management of Severe Hospital-Acquired Pneumonia

Study objectives

Design

Patients

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Am J Med

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

The prevalence of nosocomial infection in intensive care units in Europe: results of the European Prevalence of Infection in Intensive Care (EPIC) Study; EPIC International Advisory Committee

JAMA

American Thoracic Society. Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy and preventive strategies

Am J Respir Crit Care Med

Hospital-acquired pneumonia: attributable mortality and morbidity

Am J Epidemiol

Ventilator-associated pneumonia

Am J Respir Crit Care Med

Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center

Crit Care Med

Pneumonia and ARDS in patients receiving mechanical ventilation: diagnostic accuracy of chest radiography

Radiology

Diagnosis of nosocomial pneumonia in intubated, intensive care unit patients

Am Rev Respir Dis

Validation of different techniques for the diagnosis of ventilator-associated pneumonia: comparison with immediate postmortem pulmonary biopsy

Am J Respir Crit Care Med

Clinical Investigations in Critical Care
Impact of Clinical Guidelines in the Management of Severe Hospital-Acquired Pneumonia