A New Strategy for Healthcare-Associated Pneumonia: A 2-Year Prospective Multicenter- Cohort Study Using Risk Factors for Multidrug-Resistant Pathogens To Select Initial Empiric Therapy.
Clin Infect Dis. 2013 Sep 2;
Authors: Maruyama T, Fujisawa T, Okuno M, Toyoshima H, Tsutsui K, Maeda H, Yuda H, Yoshida M, Kobayashi H, Taguchi O, Gabazza EC, Takei Y, Miyashita N, Ihara T, Brito V, Niederman MS
Background. Optimal empiric therapy for hospitalized healthcare-associated pneumonia (HCAP) patients is uncertain. Methods. We prospectively applied a therapeutic algorithm, based on the presence of risk factors for multidrug-resistant (MDR) pathogens in a multicenter- cohort study of 445 pneumonia patients, including both community-acquired pneumonia (CAP, n=124) and HCAP (n=321). Results. MDR pathogens were more common (15.3% vs 0.8%, p<0.001) in HCAP patients than in CAP patients, including Staphylococcus aureus (11.5% vs 0.8%, p<0.001) ; methicillin-resistant Staphylococcus aureus (MRSA) (6.9% vs 0%, p=0.003); Enterobacteriaceae (7.8% vs 2.4%, p=0.037); and Pseudomonas aeruginosa (6.9% vs 0.8%, p=0.01). Using the proposed algorithm, HCAP patients with>2 MDR risks, one of which was severity of illness (n=170), vs. HCAP with 0-1 risk (n=151) had a significantly higher frequency of MDR pathogens (27.1% vs 2%, p<0.001). 93.1% of HCAP patients were treated according to the therapy algorithm, with only 53% receiving broad-spectrum empiric therapy, yet 92.9% received appropriate therapy for the identified pathogen. 30-day HCAP mortality was significantly higher than for CAP (13.7% vs. 5.6%, p=0.017), but among HCAP patients with 0-1 MDR risks, mortality was lower than with ≥2 MDR risks (8.6% vs. 18.2%, p=0.012). In multivariate analysis, initial treatment failure, but not inappropriate empiric antibiotic therapy, was a mortality risk factor (odds ratio 72.0). Conclusions. Basing empiric HCAP therapy on its severity and the presence of risk factors for MDR pathogens is a potentially useful approach that achieves good outcomes without excessive use of broad-spectrum antibiotic therapy.
PMID: 23999080 [PubMed - as supplied by publisher]