title: Association of guideline-based antimicrobial therapy and outcomes in healthcare-associated pneumonia.
abstract: OBJECTIVE
  Guidelines for treatment of healthcare-associated pneumonia (HCAP) recommend empirical therapy with broad-spectrum antimicrobials. Our objective was to examine the association between guideline-based therapy (GBT) and outcomes for patients with HCAP.
  
  
  METHODS
  We conducted a pharmacoepidemiological cohort study at 346 US hospitals. We included adults hospitalized between July 2007 and June 2010 for HCAP, defined as patients admitted from a nursing home, with end-stage renal disease or immunosuppression, or discharged from a hospital in the previous 90 days. Outcome measures included in-hospital mortality, length of stay and costs.
  
  
  RESULTS
  Of 85 097 patients at 346 hospitals, 31 949 (37.5%) received GBT (one agent against MRSA and at least one against Pseudomonas). Compared with patients who received non-GBT, those who received GBT had a heavier burden of chronic disease and more severe pneumonia. GBT was associated with higher mortality (17.1% versus 7.7%, P < 0.001). Adjustment for demographics, comorbidities, propensity for treatment with GBT and initial severity of disease decreased, but did not eliminate, the association (OR 1.39, 95% CI 1.32-1.47). Using an adaptation of an instrumental variable analysis, GBT was not associated with higher mortality (OR 0.93, 95% CI 0.75-1.16). Adjusted length of stay and costs were also higher with GBT.
  
  
  CONCLUSIONS
  Among patients who met HCAP criteria, GBT was not associated with lower adjusted mortality, length of stay or costs in any analyses. Better criteria are needed to identify patients at risk for MDR infections who might benefit from broad-spectrum antimicrobial coverage.
authors.affiliation: Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA rothbem@ccf.org.
authors.forename: Michael B
authors.initials: MB
authors.lastname: Rothberg
authors.affiliation: EviMed Research Group, LLC, Goshen, MA, USA.
authors.forename: Marya D
authors.initials: MD
authors.lastname: Zilberberg
authors.affiliation: Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA.
authors.forename: Penelope S
authors.initials: PS
authors.lastname: Pekow
authors.affiliation: Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA.
authors.forename: Aruna
authors.initials: A
authors.lastname: Priya
authors.affiliation: Division of Infectious Diseases, Baystate Medical Center, Springfield, MA, USA.
authors.forename: Sarah
authors.initials: S
authors.lastname: Haessler
authors.affiliation: Division of General Medicine, Baystate Medical Center, Springfield, MA, USA.
authors.forename: Raquel
authors.initials: R
authors.lastname: Belforti
authors.affiliation: Division of Infectious Diseases, Baystate Medical Center, Springfield, MA, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Skiest
authors.affiliation: Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA.
authors.forename: Tara
authors.initials: T
authors.lastname: Lagu
authors.affiliation: Division of Pulmonary/Critical Care Medicine, Baystate Medical Center, Springfield, MA, USA.
authors.forename: Thomas L
authors.initials: TL
authors.lastname: Higgins
authors.affiliation: Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA.
authors.forename: Peter K
authors.initials: PK
authors.lastname: Lindenauer
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D003428:Cross Infection / Q000188:drug therapy* / Q000401:mortality; D004363:Drug Utilization / Q000592:standards*; D005260:Female; D019983:Guideline Adherence; D017721:Hospital Costs; D006761:Hospitals; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D018410:Pneumonia, Bacterial / Q000188:drug therapy* / Q000401:mortality; D016019:Survival Analysis; D016896:Treatment Outcome; D014481:United States
chemical_list: D000900:Anti-Bacterial Agents
keywords: cohort studies; healthcare-associated infections; mortality