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Antimicrobial Therapy Escalation and Hospital Mortality Among Patients with HCAP: A Single Center Experience.
Chest. 2008 Jul 18;
Authors: Zilberberg MD, Shorr AF, Micek ST, Mody SH, Kollef MH
Background Patients with healthcare-associated pneumonia (HCAP) are frequently infected with a resistant pathogen and receive inappropriate empiric antibiotics (i.e., pathogens resistant to administered treatment). Initial inappropriate treatment has been shown to increase hospital mortality. It is not known whether escalation in response to culture results mitigates this risk. Methods We identified patients admitted with a culture-positive pneumonia between January 2003 and December 2005. HCAP patients met >/=1 of the following criteria indicating ongoing contact with the healthcare system: recent hospitalization (</=12 mos), admission from a nursing home, immunosuppression, or chronic dialysis. We compared survivors to non-survivors among those patients with HCAP still hospitalized beyond 48 hours. Results Of 431 HCAP patients, 396 (92%) were alive and still hospitalized beyond 48 hours. Crude mortality was 21.5%. Compared to survivors, non-survivors were significantly more likely to be treated with inappropriate empiric antibiotics (37.6% vs. 24.1%, p=0.013). Although mortality was higher among patients receiving inappropriate than appropriate therapy (30.0% vs. 18.3%, p=0.013), this difference was more pronounced among non-bacteremic (OR 2.45, 95% CI 1.26-4.75) than bacteremic (OR 1.25, OR 0.41-3.57) patients. In a logistic regression, inappropriate empiric antibiotic treatment among non-bacteremic patients was independently associated with mortality (OR 2.88, 95% CI 1.46-5.67); treatment escalation did not attenuate the risk of death. Conclusion Among HCAP patients alive and hospitalized beyond 48 hours, hospital mortality was high and, in the absence of bacteremia, greater with initial inappropriate antibiotic treatment. Despite subsequent escalation, initial inappropriate antibiotic choice nearly tripled the risk of hospital death.
PMID: 18641103 [PubMed - as supplied by publisher]