title: Guideline-based antibiotics and mortality in healthcare-associated pneumonia.
abstract: BACKGROUND
  Guidelines recommend administration of antibiotics with activity against methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa for treatment of healthcare-associated pneumonia (HCAP). It is unclear if this therapy improves outcomes for patients with HCAP.
  
  
  OBJECTIVE
  To determine if administration of guideline-similar therapy (GST) was associated with a reduction in 30-day mortality for HCAP.
  
  
  METHODS
  Multi-center retrospective study.
  
  
  METHODS
  Thirteen hundred and eleven admissions for HCAP in six Veterans Affairs Medical Centers.
  
  
  METHODS
  Each admission was classified as receiving GST, anti-MRSA or anti-pseudomonal components of GST, or other non-HCAP therapy initiated within 48 hours of hospitalization. Association between 30-day mortality and GST was estimated with a logistic regression model that included GST, propensity to receive GST, probability of recovering an organism from culture resistant to antibiotics traditionally used to treat community-acquired pneumonia (CAP-resistance), and a GST by CAP-resistance probability interaction.
  
  
  METHODS
  Odds ratios and 95% confidence intervals [OR (95% CI)] of 30-day mortality for patients treated with GST and predicted probability of recovering a CAP-resistant organism, and ratio of odds ratios [ROR (95% CI)] for treatment by CAP-resistance probability interaction.
  
  
  RESULTS
  Receipt of GST was associated with increased odds of 30-day mortality [OR = 2.11 (1.11, 4.04), P = 0.02)] as was the predicted probability of recovering a CAP-resistant organism [OR = 1.67 (1.26, 2.20), P < 0.001 for a 25% increase in probability]. An interaction between predicted probability of recovering a CAP-resistant organism and receipt of GST demonstrated lower mortality with GST at high probability of CAP resistance [ROR = 0.71(≤1.00) for a 25% increase in probability, P = 0.05].
  
  
  CONCLUSIONS
  For HCAP patients with high probability of CAP-resistant organisms, GST was associated with lower mortality. Consideration of the magnitude of patient-specific risk for CAP-resistant organisms should be considered when selecting HCAP therapy.
authors.affiliation: Clinical Pharmacy Service (119A), Veterans Affairs Medical Center, Boise, ID 83702, USA. KMK@pharmacy.isu.edu
authors.forename: Karl J
authors.initials: KJ
authors.lastname: Madaras-Kelly
authors.forename: Richard E
authors.initials: RE
authors.lastname: Remington
authors.forename: Kevin L
authors.initials: KL
authors.lastname: Sloan
authors.forename: Vincent S
authors.initials: VS
authors.lastname: Fan
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D003428:Cross Infection / Q000188:drug therapy* / Q000401:mortality; D004359:Drug Therapy, Combination; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D055624:Methicillin-Resistant Staphylococcus aureus; D008875:Middle Aged; D018410:Pneumonia, Bacterial / Q000188:drug therapy* / Q000401:mortality; D011023:Pneumonia, Staphylococcal / Q000188:drug therapy / Q000401:mortality; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011552:Pseudomonas Infections / Q000188:drug therapy / Q000401:mortality; D011550:Pseudomonas aeruginosa; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology
chemical_list: D000900:Anti-Bacterial Agents