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Published on: August 30, 2018
Implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care: an
Daniel H Kett1, Ennie Cano, Andrew A Quartin
1University of Miami, Jackson Memorial Hospital, and Veterans Affairs Medical Center, Miami, FL 33156, USA. dkett@med.miami.edu
Insights
Adherence to pneumonia treatment guidelines was associated with higher mortality in intensive care units. Further randomized trials are needed before widespread implementation of these hospital-acquired pneumonia protocols.
Area of Science:
- Infectious Diseases
- Critical Care Medicine
- Clinical Practice Guidelines
Background:
- Guidelines exist for managing hospital-acquired, ventilator-associated, and health-care-associated pneumonias, focusing on empirical antibiotic regimens for multidrug-resistant pathogens.
- A performance-improvement initiative was launched to enhance compliance with these guidelines and evaluate patient outcomes.
Purpose of the Study:
- To improve compliance with established guidelines for pneumonia management.
- To assess the impact of guideline compliance on patient outcomes in intensive care units.
Main Methods:
- A prospective observational study was conducted across four US academic medical centers.
- Patients in intensive care units at risk for multidrug-resistant pneumonia received empirical treatment and were followed for 28 days.
Main Results:
- Guideline compliance was observed in 129 of 303 patients (43%).
- 28-day mortality was higher in the compliant group (34%) compared to the non-compliant group (20%), with a 28-day survival of 65% vs. 79% (p=0.0042).
- Compliance failures included inadequate Gram-negative and methicillin-resistant Staphylococcus aureus coverage.
Conclusions:
- Adherence to empirical treatment guidelines was paradoxically associated with increased mortality.
- A randomized trial is recommended to validate these findings before further implementation of the guidelines.
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.
Findings:
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.
Interpretation:
Because adherence with empirical treatment was associated with increased mortality, we recommend a randomised trial be done before further implementation of these guidelines.
Funding:
Pfizer, US Medical.
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