Guideline-adherent initial intravenous antibiotic therapy for hospital-acquired/ventilator-associated pneumonia is clinically superior, saves lives and is cheaper than non guideline adherent therapy

Abstract

IntroductionHospital-acquired pneumonia (HAP) often occurring as ventilator-associated pneumonia (VAP) is the most frequent hospital infection in intensive care units (ICU). Early adequate antimicrobial therapy is an essential determinant of clinical outcome. Organisations like the German PEG or ATS/IDSA provide guidelines for the initial calculated treatment in the absence of pathogen identification. We conducted a retrospective chart review for patients with HAP/VAP and assessed whether the initial intravenous antibiotic therapy (IIAT) was adequate according to the PEG guidelinesMaterials and methodsWe collected data from 5 tertiary care hospitals. Electronic data filtering identified 895 patients with potential HAP/VAP. After chart review we finally identified 221 patients meeting the definition of HAP/VAP. Primary study endpoints were clinical improvement, survival and length of stay. Secondary endpoints included duration of mechanical ventilation, total costs, costs incurred on the intensive care unit (ICU), costs incurred on general wards and drug costs.ResultsWe found that 107 patients received adequate initial intravenous antibiotic therapy (IIAT) vs. 114 with inadequate IIAT according to the PEG guidelines. Baseline characteristics of both groups revealed no significant differences and good comparability. Clinical improvement was 64% over all patients and 82% (85/104) in the subpopulation with adequate IIAT while only 47% (48/103) inadequately treated patients improved (p < 0.001). The odds ratio of therapeutic success with GA versus NGA treatment was 5.821 (p < 0.001, [95% CI: 2.712-12.497]). Survival was 80% for the total population (n = 221), 86% in the adequately treated (92/107) and 74% in the inadequately treated 'subpopulation (84/114) (p = 0.021). The odds ratio of mortality for GA vs. NGA treatment was 0.565 (p = 0.117, [95% CI: 0.276-1.155]). Adequately treated patients had a significantly shorter length of stay (LOS) (23.9 vs. 28.3 days; p = 0.022), require significantly less hours of mechanical ventilation (175 vs. 274; p = 0.001), incurred lower total costs (EUR 28,033 vs. EUR 36,139, p = 0.006) and lower ICU-related costs (EUR 13,308 vs. EUR 18,666, p = 0.003).Drug costs for the hospital stay were also lower (EUR 4,069 vs. EUR 4,833) yet not significant. The most frequent types of inadequate therapy were monotherapy instead of combination therapy, wrong type of penicillin and wrong type of cephalosporin.DiscussionThese findings are consistent with those from other studies analyzing the impact of guideline adherence on survival rates, clinical success, LOS and costs. However, inadequately treated patients had a higher complicated pathogen risk score (CPRS) compared to those who received adequate therapy. This shows that therapy based on local experiences may be sufficient for patients with low CPRS but inadequate for those with high CPRS. Linear regression models showed that single items of the CPRS like extrapulmonary organ failure or late onset had no significant influence on the results.C...

Adherence to antibiotic treatment guidelines and outcomes in the hospitalized elderly with different types of pneumonia

“…While several studies on adherence to guidelines of empirical antibiotic therapy for CAP have been conducted in medical wards and intensive care units [6,[13][14][15], a relatively small number of studies have investigated adherence in patients with healthcare-associated pneumonias such as HAP or HCAP [7,[16][17][18][19].…”

Ventilator-associated pneumonia: present understanding and ongoing debates

“…In another multicenter trial with 740 mechanically ventilated patients, combination therapy with meropenem and ciprofloxacin increased the likelihood of appropriate empiric therapy in VAP for those with MDR pathogens (84.2 vs. 18.8 %, p \ 0.001), but had no impact on mortality; however, in this population, MDR pathogens were uncommon [44]. In a study with initial empiric antibiotic therapy based on the German PEG guidelines, clinical improvement occurred in 82 % of the guideline-adherent group compared to 47 % in the non-adherent group (p = 0.001), with better survival in the guideline-adherent group (86 vs. 74 %, p = 0.021) [45].…”

Healthcare Resource Utilization and Cost Related to Nosocomial Pneumonia Caused by Staphylococcus aureus and Pseudomonas aeruginosa in France: A 2010-2011 Population-Based Cohort Study Using a National Claims Database

“…Resistant infections may lead to treatment failures and the need to use second or third-line antibiotics, increased length of stay, and/or mortality. Studies have also demonstrated that healthcare resource utilization typically rises with failure of initial empiric therapy [24][25][26][27].…”