Guideline-based antibiotics and mortality in healthcare-associated pneumonia
Karl J Madaras-Kelly1, Richard E Remington, Kevin L Sloan
1Clinical Pharmacy Service (119A), Veterans Affairs Medical Center, Boise, ID 83702, USA. KMK@pharmacy.isu.edu
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.
Design:
Multi-center retrospective study.
Participants:
Thirteen hundred and eleven admissions for HCAP in six Veterans Affairs Medical Centers.
Interventions:
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.
Main Measures:
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.
Key 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.
Insights
Guideline-similar therapy (GST) for healthcare-associated pneumonia (HCAP) may increase mortality, but it reduces deaths in patients with a high risk of antibiotic-resistant infections. Tailoring HCAP treatment to individual patient risk factors is crucial.
Area of Science:
- Infectious Diseases
- Clinical Pharmacy
- Critical Care Medicine
Background:
- Current guidelines recommend broad-spectrum antibiotics for healthcare-associated pneumonia (HCAP), targeting methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa.
- The clinical benefit of this guideline-similar therapy (GST) in improving patient outcomes for HCAP remains uncertain.
Purpose of the Study:
- To investigate the association between guideline-similar therapy (GST) administration and 30-day mortality in patients diagnosed with HCAP.
- To explore the impact of GST on mortality in relation to the predicted probability of infection with antibiotic-resistant organisms.
Main Methods:
- A multi-center retrospective study involving 1311 HCAP admissions across six Veterans Affairs Medical Centers.
- Patients were categorized based on receiving GST, partial GST components, or other therapies within 48 hours of admission.
- Logistic regression analysis was employed to assess the association between GST, patient-specific resistance probability, and 30-day mortality.
Main Results:
- Receipt of GST was associated with increased odds of 30-day mortality (OR = 2.11).
- A higher predicted probability of infection with community-acquired pneumonia (CAP)-resistant organisms also correlated with increased mortality (OR = 1.67).
- An interaction effect was observed, indicating that GST was associated with lower mortality in patients with a high probability of CAP-resistant organisms (ROR = 0.71).
Conclusions:
- Guideline-similar therapy (GST) may be associated with reduced mortality in HCAP patients who have a high predicted risk of infection with antibiotic-resistant organisms.
- Clinical decisions regarding HCAP treatment should incorporate patient-specific risk assessments for antibiotic resistance to optimize therapeutic strategies.
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