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


METHODS
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.


RESULTS
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.


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


BACKGROUND
Pfizer, US Medical.
University of Miami, Jackson Memorial Hospital, and Veterans Affairs Medical Center, Miami, FL 33156, USA. dkett@med.miami.edu
Daniel H
DH
Kett
Ennie
E
Cano
Andrew A
AA
Quartin
Julie E
JE
Mangino
Marcus J
MJ
Zervos
Paula
P
Peyrani
Cynthia M
CM
Cely
Kimbal D
KD
Ford
Ernesto G
EG
Scerpella
Julio A
JA
Ramirez
D000293:Adolescent; D000328:Adult; D015331:Cohort Studies; D003428:Cross Infection / Q000517:prevention & control*; D024901:Drug Resistance, Multiple, Bacterial; D006801:Humans; D007362:Intensive Care Units / Q000592:standards*; D008875:Middle Aged; D018410:Pneumonia, Bacterial / Q000188:drug therapy* / Q000209:etiology / Q000382:microbiology*; D053717:Pneumonia, Ventilator-Associated / Q000188:drug therapy* / Q000382:microbiology*; D017410:Practice Guidelines as Topic; D012955:Societies, Medical; D016896:Treatment Outcome; D055815:Young Adult