Journal Article

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

Mangino, Julie E, Scerpella, Ernesto G, Kett, Daniel H, Quartin, Andrew A, Cely, Cynthia M, Ramirez, Julio A, Cano, Ennie, Ford, Kimbal D, Zervos, Marcus J, Peyrani, Paula

2011

Overview

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

• Publisher: Elsevier Ltd,Lancet Publishing Group,Elsevier Limited
• Subject: Adolescent / Adult / Biological and medical sciences / Cohort Studies / Cross Infection - prevention & control / Drug Resistance, Multiple, Bacterial / Humans / Infectious Disease / Infectious diseases / Intensive Care Units - standards / Medical sciences / Middle Aged / Pathogens / Pneumology / Pneumonia, Bacterial - drug therapy / Pneumonia, Bacterial - etiology / Pneumonia, Bacterial - microbiology / Pneumonia, Ventilator-Associated - drug therapy / Pneumonia, Ventilator-Associated - microbiology / Practice Guidelines as Topic / Public health / Respiratory system : syndromes and miscellaneous diseases / Societies, Medical / Treatment Outcome / Young Adult