This paper is only available as a PDF. To read, Please Download here.
Abstract
Objective: This study evaluated the survival benefit of US community-acquired pneumonia (CAP)
practice guidelines in the intensive care unit (ICU) setting.
Methods: We conducted a retrospective cohort study of adult patients with CAP who were admitted
to 5 community hospital ICUs between November 1, 1999, and April 30, 2000. The guidelines
for antibiotic prescriptions were the 2007 Infectious Diseases Society of America/American
Thoracic Society guidelines. Guideline-concordant antimicrobial therapy was defined
as a β-lactam plus fluoroquinolone or macrolide, antipseudomonal β-lactam plus fluoroquinolone,
or antipseudomonal β-lactam plus aminoglycoside plus fluoroquinolone or macrolide.
Patients with a documented β-lactam allergy were considered to have received guideline-concordant
therapy if they received a fluoroquinolone with or without clindamycin, or aztreonam
plus fluoroquinolone with or without aminoglycoside. All other antibiotic regimens
were considered to be guideline discordant. Time to clinical stability, time to oral
antibiotics, length of hospital stay, and in-hospital mortality were evaluated with
regression models that included the outcome as the dependent variable, guidelineconcordant
antibiotic therapy as the independent variable, and the Pneumonia Severity Index (PSI)
score and facility as covariates.
Results: The median age of the 129 patients included in the study was 71 years (interquartile
range, 60–79 years). Sixty-two of 129 patients (48%) were male. Comorbidities included
liver dysfunction (7 patients [5%]), heart failure (62 [48%]), renal dysfunction (39
[30%]), cerebrovascular disease (21 [16%]), and cancer (14 [11%]). The median (25th–75th
percentile) PSI score was 119 (98–142), and overall mortality was 19% (25 patients).
Patient demographics were similar between groups. Fifty-three patients (41%) received
guideline-endorsed therapies. Guideline-discordant therapy was associated with an
increase in inpatient mortality (25% vs 11%; odds ratio = 2.99 [95% CI, 1.08–9.54]).
Receipt of guideline-concordant antibiotics was not associated with reductions in
time to clinical stability, time to oral antibiotics, or length of hospital stay when
patients who died were excluded from the analysis.
Conclusion: Guideline-concordant empiric antibiotic therapy was associated with improved survival
among these patients with CAP who were admitted to 5 ICUs.
Key words
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Clinical TherapeuticsAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- 2006 National Hospital Discharge Survey. National Center for Health Statistics, Hyattsville, Md2008 (National Health Statistics Report no 5.)
- Deaths: Final Data for 2005. vol. 56. National Center for Health Statistics, Hyattsville, Md2008 (National Vital Statistics Reports, no. 10.)
- Severe community-acquired pneumonia: Use of intensive care services and evaluation of American and British Thoracic Society Diagnostic criteria.Am J Respir Crit Care Med. 2002; 166: 717-723
- Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia.Arch Intern Med. 2004; 164: 637-644
- Associations between initial antimicrobial therapy and medical outcomes for hospitalized elderly patients with pneumonia.Arch Intern Med. 1999; 159: 2562-2572
- Measuring quality of care with explicit process criteria before and after implementation of the DRG-based prospective payment system.JAMA. 1990; 264: 1969-1973
- Infectious Diseases Society of America/ American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults.Clin Infect Dis. 2007; 44: S27-S72
- Community-acquired pneumonia in adults: Guidelines for management.Clin Infect Dis. 1998; 26: 811-838
- Practice guidelines for the management of community-acquired pneumonia in adults.Clin Infect Dis. 2000; 31: 347-382
- Effects of a pneumonia clinical pathway on time to antibiotic treatment, length of stay, and mortality.Acad Emerg Med. 1999; 6: 1243-1248
- Improvement of process-of-care and outcomes after implementing a guideline for the management of community-acquired pneumonia: A controlled beforeand-after design study.Clin Infect Dis. 2004; 39: 955-963
- Decreased mortality after implementation of a treatment guideline for community-acquired pneumonia.Am J Med. 2001; 110: 451-457
- Implementation of an evidence-based guideline to reduce duration of intravenous antibiotic therapy and length of stay for patients hospitalized with community-acquired pneumonia: A randomized controlled trial.Am J Med. 2003; 115: 343-351
- A controlled trial of a critical pathway for treatment of communityacquired pneumonia. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin.JAMA. 2000; 283: 749-755
- Factors influencing in-hospital mortality in community-acquired pneumonia: A prospective study of patients not initially admitted to the ICU.Chest. 2005; 127: 1260-1270
- Influence of deviation from guidelines on the outcome of community-acquired pneumonia.Chest. 2002; 122: 612-617
- Effects of guideline-concordant antimicrobial therapy on mortality among patients with community-acquired pneumonia.Am J Med. 2004; 117: 726-731
- Antibiotic prescription for community- acquired pneumonia in the intensive care unit: Impact of adherence to Infectious Diseases Society of America guidelines on survival.Clin Infect Dis. 2005; 41: 1709-1716
- Impact of guidelineconcordant empiric antibiotic therapy in community-acquired pneumonia.Am J Med. 2006; 119: 865-871
- A prediction rule to identify low-risk patients with community-acquired pneumonia.N EnglJ Med. 1997; 336: 243-250
- Time to clinical stability in patients hospitalized with community-acquired pneumonia: Implications for practice guidelines.JAMA. 1998; 279: 1452-1457
- Reaching stability in community-acquired pneumonia: The effects of the severity of disease, treatment, and the characteristics of patients.Clin Infect Dis. 2004; 39: 1783-1790
Article info
Publication history
Accepted:
November 10,
2009
Identification
Copyright
© 2010 Published by Elsevier Inc.
