Implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care

An observational, multicentre cohort study

Daniel H Kett, Ennie Cano, Andrew Quartin, Julie E. Mangino, Marcus J. Zervos, Paula Peyrani, Cynthia M. Cely, Kimbal D. Ford, Ernesto G. Scerpella, Julio A. Ramirez

Research output: Contribution to journalArticle

158 Citations (Scopus)

Abstract

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.

Original languageEnglish
Pages (from-to)181-189
Number of pages9
JournalThe Lancet Infectious Diseases
Volume11
Issue number3
DOIs
StatePublished - Mar 1 2011

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Critical Care
Multicenter Studies
Pneumonia
Cohort Studies
Guidelines
Compliance
Therapeutics
Methicillin
Lost to Follow-Up
Mechanical Ventilators
Patient Compliance
Artificial Respiration
Intensive Care Units
Staphylococcus aureus
Length of Stay
Observation
Anti-Bacterial Agents
Delivery of Health Care
Education

ASJC Scopus subject areas

  • Infectious Diseases

Cite this

Implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care : An observational, multicentre cohort study. / Kett, Daniel H; Cano, Ennie; Quartin, Andrew; Mangino, Julie E.; Zervos, Marcus J.; Peyrani, Paula; Cely, Cynthia M.; Ford, Kimbal D.; Scerpella, Ernesto G.; Ramirez, Julio A.

In: The Lancet Infectious Diseases, Vol. 11, No. 3, 01.03.2011, p. 181-189.

Research output: Contribution to journalArticle

Kett, Daniel H ; Cano, Ennie ; Quartin, Andrew ; Mangino, Julie E. ; Zervos, Marcus J. ; Peyrani, Paula ; Cely, Cynthia M. ; Ford, Kimbal D. ; Scerpella, Ernesto G. ; Ramirez, Julio A. / Implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care : An observational, multicentre cohort study. In: The Lancet Infectious Diseases. 2011 ; Vol. 11, No. 3. pp. 181-189.
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