Health care–associated pneumonia in the intensive care unit: Guideline-concordant antibiotics and outcomes

Abstract

Purpose Recent data have not demonstrated improved outcomes when guideline-concordant (GC) antibiotics are given to patients with healthcare-associated pneumonia (HCAP). This study was designed to evaluate the relationship between health outcomes and GC therapy in patients admitted to an ICU with HCAP. Materials and Methods We performed a population-based cohort study of patients admitted to >150 hospitals in the U.S. Veterans Health Administration system to compare baseline characteristics, bacterial pathogens, and health outcomes in ICU patients with HCAP receiving either GC-HCAP therapy, GC community-acquired pneumonia (GC-CAP) therapy, or non-GC therapy. The primary outcome was 30-day patient mortality. Risk factors for the primary outcome were assessed in a multivariable logistic regression model. Results A total of 3,593 patients met inclusion criteria and received GC-HCAP therapy (26%), GC-CAP therapy (23%), or non-GC therapy (51%). GC-HCAP patients had higher 30-day patient mortality compared to GC-CAP patients (34% vs. 22%, p<0.0001). After controlling for confounders, risk factors for 30-day patient mortality were vasopressor use (OR, 95% CI; 1.67, 1.30–2.13), recent hospital admission (1.53, 1.15–2.02), and receipt of GC-HCAP therapy (1.51, 1.20–1.90). Conclusions Our data do not demonstrate improved outcomes among ICU patients with HCAP who received GC-HCAP therapy.

Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America

“…Since then, many studies have demonstrated that the factors used to define HCAP do not predict high prevalence of antibiotic-resistant pathogens in most settings. Moreover, a significant increased use of broad-spectrum antibiotics (especially vancomycin and antipseudomonal β-lactams) has resulted, without any apparent improvement in patient outcomes ( 124 – 133 ).…”

A Prospective One-Year Microbiologic Survey of Combined Pneumonia and Respiratory Failure

“…However, this approach of ''clinical reasoning,'' even when supplemented by institution-specific algorithms developed for the prediction of infection with antibiotic-resistant bacteria, is of limited clinical utility [17]. This inaccuracy in clinical decision-making often leads to overtreatment with empiric broad-spectrum antibiotics but also the administration of IIAT [17,18]. The recent recommendation to eliminate the use of the term ''HCAP'' is in large part a response to the increasing use of empiric broadspectrum antibiotics in patients with community-onset pneumonia [10,19].…”

Emerging Resistance of Gram Negative Pathogens in Community-Acquired Pneumonia

“…69 Concerns about adverse events and antibiotic resistance in patients who received broad spectrum antibiotic therapy were raised and an increasing body of evidence showed a greater risk of mortality in patients with HCAP risk factors who received broad-spectrum therapy relative to patients treated with standard CAP therapy. 70,71 To address these limitations of the HCAP definition, scientists developed multiple clinical prediction models attempting to identify MDR pathogens in CAP. 5,16,17,19,[72][73][74][75][76] Although these scores showed an area under the receiver operating characteristic (AUROC) curve higher than the original HCAP criteria in predicting pneumonia due to resistant pathogens, they were not designed to predict the risk of each individual MDR pathogen, such as MRSA or P. aeruginosa, with few exceptions.…”