title: Antimicrobial de-escalation of treatment for healthcare-associated pneumonia within the Veterans Healthcare Administration.
abstract: OBJECTIVE
  The objective of this study was to measure quantitatively antimicrobial de-escalation utilizing electronic medication administration data based on the spectrum of activity for antimicrobial therapy (i.e. spectrum score) to identify variables associated with de-escalation in a nationwide healthcare system.
  
  
  METHODS
  A retrospective cohort study of patients hospitalized for healthcare-associated pneumonia was conducted in Veterans Affairs Medical Centers (n = 119). Patients hospitalized for healthcare-associated pneumonia on acute-care wards between 5 and 14 days who received antimicrobials for ≥ 3 days during calendar years 2008-11 were evaluated. The spectrum score method was applied at the patient level to measure de-escalation on day 4 of hospitalization. De-escalation was expressed in aggregate and facility-level proportions. Logistic regression was used to assess variables associated with de-escalation. ORs with 95% CIs were reported.
  
  
  RESULTS
  Among 9319 patients, the de-escalation proportion was 28.3% (95% CI 27.4-29.2), which varied 6-fold across facilities [median (IQR) facility-level de-escalation proportion 29.1% (95% CI 21.7-35.6)]. Variables associated with de-escalation included initial broad-spectrum therapy (OR 1.5, 95% CI 1.4-1.5 for each 10% increase in spectrum), collection of respiratory tract cultures (OR 1.1, 95% CI 1.0-1.2) and care in higher complexity facilities (OR 1.3, 95% CI 1.1-1.6). Respiratory tract cultures were collected from 35.3% (95% CI 32.7-37.7) of patients.
  
  
  CONCLUSIONS
  De-escalation of antimicrobial therapy was limited and varied substantially across facilities. De-escalation was associated with respiratory tract culture collection and treatment in a high complexity-level facility.
authors.affiliation: Boise Veterans Affairs Medical Center, T111, 500 W. Fort Street, Boise, ID 83702, USA College of Pharmacy, Idaho State University, Meridian, ID, USA kmk@pharmacy.isu.edu.
authors.forename: Karl
authors.initials: K
authors.lastname: Madaras-Kelly
authors.affiliation: George E. Whalen Veterans Affairs Medical Center, Salt Lake City, UT, USA Division of Epidemiology, University of Utah, Salt Lake City, UT, USA.
authors.forename: Makoto
authors.initials: M
authors.lastname: Jones
authors.affiliation: Boise Veterans Affairs Medical Center, T111, 500 W. Fort Street, Boise, ID 83702, USA Quantified Inc., Boise, ID, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Remington
authors.affiliation: Boise Veterans Affairs Medical Center, T111, 500 W. Fort Street, Boise, ID 83702, USA College of Pharmacy, Idaho State University, Meridian, ID, USA.
authors.forename: Christina M
authors.initials: CM
authors.lastname: Caplinger
authors.affiliation: Division of Infectious Diseases and Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
authors.forename: Benedikt
authors.initials: B
authors.lastname: Huttner
authors.affiliation: George E. Whalen Veterans Affairs Medical Center, Salt Lake City, UT, USA Division of Pulmonology and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA.
authors.forename: Barbara
authors.initials: B
authors.lastname: Jones
authors.affiliation: George E. Whalen Veterans Affairs Medical Center, Salt Lake City, UT, USA Division of Epidemiology, University of Utah, Salt Lake City, UT, USA.
authors.forename: Matthew
authors.initials: M
authors.lastname: Samore
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D003428:Cross Infection / Q000188:drug therapy*; D004358:Drug Therapy / Q000379:methods; D005260:Female; D006787:Hospitals, Veterans; D006801:Humans; D008297:Male; D018410:Pneumonia, Bacterial / Q000188:drug therapy*; D012189:Retrospective Studies
chemical_list: D000900:Anti-Bacterial Agents