title: Antimicrobial therapy escalation and hospital mortality among patients with health-care-associated pneumonia: a single-center experience.
abstract: BACKGROUND
  Patients with health-care-associated pneumonia (HCAP) are frequently infected with a resistant pathogen and receive inappropriate empiric antibiotics (ie, pathogens resistant to administered treatment). Initial inappropriate treatment has been shown to increase hospital mortality. It is not known whether escalation in response to culture results mitigates this risk.
  
  
  METHODS
  We identified patients admitted with a culture-positive pneumonia between January 2003 and December 2005. HCAP patients met one or more of the following criteria indicating ongoing contact with the health-care system: recent hospitalization (< or = 12 months), admission from a nursing home, immunosuppression, or long-term dialysis. We compared survivors to nonsurvivors among those patients with HCAP still hospitalized beyond 48 h.
  
  
  RESULTS
  Of 431 HCAP patients, 396 patients (92%) were alive and still hospitalized beyond 48 h. The crude mortality rate was 21.5%. Compared to survivors, nonsurvivors were significantly more likely to be treated with inappropriate empiric antibiotics (37.6% vs 24.1%, p = 0.013). Although mortality was higher among patients receiving inappropriate than appropriate therapy (30.0% vs 18.3%, p = 0.013), this difference was more pronounced among nonbacteremic patients (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.26 to 4.75) than bacteremic patients (OR, 1.25; 95% CI, 0.41 to 3.57). In a logistic regression, inappropriate empiric antibiotic treatment among nonbacteremic patients was independently associated with mortality (OR, 2.88; 95% CI, 1.46 to 5.67); treatment escalation did not attenuate the risk of death.
  
  
  CONCLUSIONS
  Among HCAP patients alive and hospitalized beyond 48 h, hospital mortality was high and, in the absence of bacteremia, greater with initial inappropriate antibiotic treatment. Despite subsequent escalation, initial inappropriate antibiotic choice nearly tripled the risk of hospital death.
authors.affiliation: School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA. Electronic address: MZilberb@schoolph.umass.edu.
authors.forename: Marya D
authors.initials: MD
authors.lastname: Zilberberg
authors.affiliation: Washington Hospital Center, Washington, DC.
authors.forename: Andrew F
authors.initials: AF
authors.lastname: Shorr
authors.affiliation: Barnes-Jewish Hospital, St Louis, MO.
authors.forename: Scott T
authors.initials: ST
authors.lastname: Micek
authors.affiliation: Ortho-McNeil Janssen Scientific Affairs, LLC, Raritan, NJ.
authors.forename: Samir H
authors.initials: SH
authors.lastname: Mody
authors.affiliation: Barnes-Jewish Hospital, St Louis, MO.
authors.forename: Marin H
authors.initials: MH
authors.lastname: Kollef
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016001:Confidence Intervals; D003428:Cross Infection / Q000188:drug therapy* / Q000401:mortality*; D024881:Drug Resistance, Bacterial; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008508:Medication Errors / Q000401:mortality; D008875:Middle Aged; D016017:Odds Ratio; D018410:Pneumonia, Bacterial / Q000188:drug therapy* / Q000401:mortality*; D012189:Retrospective Studies; D012307:Risk Factors; D014481:United States / Q000453:epidemiology
chemical_list: D000900:Anti-Bacterial Agents