title: Inadequate treatment of ventilator-associated and hospital-acquired pneumonia: risk factors and impact on outcomes.
abstract: BACKGROUND
  Initial antimicrobial therapy (AB) is an important determinant of clinical outcome in patients with severe infections as pneumonia, however well-conducted studies regarding prognostic impact of inadequate initial AB in patients who are not undergoing mechanical ventilation (MV) are lacking. In this study we aimed to identify the risk factors for inadequate initial AB and to determine its subsequent impact on outcomes in both ventilator associated pneumonia (VAP) and hospital acquired pneumonia (HAP).
  
  
  METHODS
  We retrospectively studied the accuracy of initial AB in patients with pneumonia in a university hospital in Turkey. A total of 218 patients with HAP and 130 patients with VAP were included. For each patient clinical, radiological and microbiological data were collected. Stepwise multivariate logistic regression analysis was used for risk factor analysis. Survival analysis was performed by using Kaplan-Meier method with Log-rank test.
  
  
  RESULTS
  Sixty six percent of patients in VAP group and 41.3% of patients in HAP group received inadequate initial AB. Multiple logistic regression analysis revealed that the risk factors for inadequate initial AB in HAP patients were; late-onset HAP (OR = 2.35 (95% CI, 1.05-5.22; p = 0.037) and APACHE II score at onset of HAP (OR = 1.06 (95% CI, 1.01-1.12); p = 0.018). In VAP patients; antibiotic usage in the previous three months (OR = 3.16 (95% CI, 1.27-7.81); p = 0.013) and admission to a surgical unit (OR = 2.9 (95% CI, 1.17-7.19); p = 0.022) were found to be independent risk factors for inadequate initial AB. No statistically significant difference in crude hospital mortality and 28-day mortality was observed between the treatment groups in both VAP and HAP. However we showed a significant increase in length of hospital stay, duration of mechanical ventilation and a prolonged clinical resolution in the inadequate AB group in both VAP and HAP.
  
  
  CONCLUSIONS
  Our data suggests that the risk factors for inadequate initial AB are indirectly associated with the acquisition of resistant bacteria for both VAP and HAP. Although we could not find a positive correlation between adequate initial AB and survival; empirical AB with a broad spectrum should be initiated promptly to improve secondary outcomes.
authors.affiliation: Departments of Infectious Diseases and Clinical Microbiology, School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey. nihal_piskin@yahoo.com
authors.forename: Nihal
authors.initials: N
authors.lastname: Piskin
authors.forename: Hande
authors.initials: H
authors.lastname: Aydemir
authors.forename: Nefise
authors.initials: N
authors.lastname: Oztoprak
authors.forename: Deniz
authors.initials: D
authors.lastname: Akduman
authors.forename: Fusun
authors.initials: F
authors.lastname: Comert
authors.forename: Furuzan
authors.initials: F
authors.lastname: Kokturk
authors.forename: Guven
authors.initials: G
authors.lastname: Celebi
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D015331:Cohort Studies; D024881:Drug Resistance, Bacterial; D005260:Female; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008875:Middle Aged; D018410:Pneumonia, Bacterial / Q000175:diagnosis* / Q000188:drug therapy* / Q000382:microbiology; D053717:Pneumonia, Ventilator-Associated / Q000175:diagnosis* / Q000188:drug therapy* / Q000382:microbiology; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D016896:Treatment Outcome; D014421:Turkey
chemical_list: D000900:Anti-Bacterial Agents