0
Original Research: PNEUMONIA |

Using Local Microbiologic Data To Develop Institution-Specific Guidelines for the Treatment of Hospital-Acquired Pneumonia* FREE TO VIEW

James R. Beardsley, PharmD; John C. Williamson, PharmD; James W. Johnson, PharmD; Christopher A. Ohl, MD; Tobi B. Karchmer, MD, MS; David L. Bowton, MD, FCCP
Author and Funding Information

*From the Department of Pharmacy (Drs. Beardsley, Williamson, and Johnson), Section of Infectious Diseases (Drs. Ohl and Karchmer), and Department of Anesthesiology, Section on Critical Care (Dr. Bowton), Wake Forest University Baptist Medical Center, Winston-Salem, NC.

Correspondence to: James R. Beardsley, PharmD, Department of Pharmacy, Wake Forest University Baptist Medical Center, Medical Center Blvd, Winston-Salem, NC 27157; e-mail: jbeardsl@wfubmc.edu



Chest. 2006;130(3):787-793. doi:10.1378/chest.130.3.787
Text Size: A A A
Published online

Background: While current guidelines recommend consideration of local microbiologic data when selecting empiric treatment for hospital-acquired pneumonia (HAP), few specifics of how to do this have been offered.

Methods: We conducted a retrospective analysis of HAP pathogens in 111 consecutive patients who acquired HAP during July to December 2004 and had a corresponding positive culture finding for a bacterial pathogen. These data were used to develop institution-specific guidelines.

Results: The most common bacteria identified were Staphylococcus aureus, Acinetobacter baumannii, and Pseudomonas aeruginosa, which were associated with 38%, 25%, and 19% of pneumonias, respectively. Susceptibility of Gram-negative bacteria to piperacillin-tazobactam and cefepime was 80% and 81%, respectively. The isolation of organisms resistant to piperacillin-tazobactam or cefepime was significantly more frequent in patients who had been hospitalized ≥ 10 days. Of Gram-negative isolates resistant to piperacillin-tazobactam or cefepime, ciprofloxacin was active against < 10%, while amikacin was active against > 80%. New treatment guidelines were developed that divided the American Thoracic Society/Infectious Diseases Society of America “late onset/risk of multidrug-resistant pathogens” group of patients into two subcategories: “early-late” pneumonias (< 10 days of hospitalization) and “late-late” pneumonias (≥ 10 days of hospitalization). Guideline-directed treatment regimens would be predicted to provide adequate initial therapy for > 90% of late-onset pneumonias at our institution.

Conclusions: Current guidelines suggest adding either an aminoglycoside or a fluoroquinolone to β-lactam therapy for empiric Gram-negative coverage. However, in our institution, adding ciprofloxacin would not appreciably enhance the likelihood of providing initial appropriate antibiotic coverage. This underscores the importance of employing a systematic analysis of local data when developing treatment guidelines.

Figures in this Article

Hospital-acquired pneumonia (HAP) is the second-most-common nosocomial infection and accounts for approximately one fourth of all infections in the ICU.12 New guidelines from the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) for the management of adults with HAP, ventilator-associated pneumonia, and health-care–associated pneumonia stress the clinical benefit of adequate initial therapy, defined as providing initial therapy with agents having in vitro activity against the identified microorganism(s) causing the infection.3 Ibrahim and colleagues4demonstrated that local treatment guidelines advocating the use of broad-spectrum combination therapy can greatly improve the likelihood of providing adequate initial therapy to patients with HAP. Similar findings were recently published by Hoo et al,5 who also found a reduction in 14-day mortality associated with guideline-directed therapy. The ATS/IDSA guidelines recommend broad empiric therapy for patients at risk for pneumonia caused by multidrug-resistant (MDR) pathogens.3 While these guidelines, and the work of others,67 stress the importance of basing empiric treatment regimens on local pathogen prevalence and susceptibilities, specific recommendations on how to incorporate local microbiologic data into institution-specific guidelines are not widely agreed upon.

Wake Forest University Baptist Medical Center includes an 830-bed tertiary-care hospital with 115 adult critical-care beds and 26 step-down intermediate-care beds. Policies governing the use of anti-infectives are developed by the institution’s Center for Antimicrobial Utilization, Stewardship, and Epidemiology (CAUSE).8 The CAUSE Advisory Board undertook the development of institution-specific HAP guidelines incorporating local microbiologic data to optimize the adequacy of initial empiric therapy. An initial step in this process was a formal evaluation of the pathogens causing HAP at Wake Forest University Baptist Medical Center.

Our Department of Infection Control compiled a list of consecutive patients located in an adult medical or surgical ICU or the intermediate-care unit who met the Centers for Disease Control and Prevention criteria for HAP9 and had an associated positive culture finding for a bacterial pathogen. We evaluated patients from this list who acquired HAP during July to December 2004. Data obtained from the Department of Infection Control included patient medical record number, date of admission, date of pneumonia onset, primary service, unit, ventilator status, and date of respiratory cultures. Electronic medical records were searched to determine the source of respiratory cultures (BAL, protected specimen brush, or tracheal aspirate) and the associated bacterial concentration. Bacteria with significant growth (defined as ≥ 103 cfu/mL for protected specimen brush, ≥ 104 cfu/mL for BAL, ≥ 105 cfu/mL for tracheal aspirate, and at least 2+ for semiquantitative cultures) were recorded. The susceptibilities to gentamicin, amikacin, cefepime, piperacillin-tazobactam, meropenem, and ciprofloxacin were recorded for each Gram-negative isolate, as were the susceptibilities to oxacillin, penicillin, and vancomycin for staphylococcal, streptococcal, and enterococcal isolates, respectively. Antimicrobial susceptibilities were determined by broth microdilution applying the breakpoints recommended by the Clinical and Laboratory Standards Institute.

The hospital day of onset for each episode of pneumonia was calculated, and pneumonias were classified as being either early onset (occurring prior to or on day 4 of hospitalization) or late onset (occurring > 4 days of hospitalization). The percentage of total isolates and pneumonia episodes represented by each organism was tabulated. The following were determined: onset of pneumonias (early vs late), percentage of Staphylococcus aureus isolates sensitive to oxacillin, and the percentage of all Gram-negative isolates sensitive to each of the six antibiotics targeting Gram-negative pathogens. For isolates not susceptible to either piperacillin-tazobactam or cefepime, the susceptibilities to the other five Gram-negative agents were evaluated, as was the day of onset of the pneumonias caused by these resistant pathogens. The coverage offered by antibiotic combinations against the Gram-negative isolates was also assessed.

The adequacy of different empiric antibiotic combinations was determined for each episode of late-onset pneumonia. An adequate regimen was defined as a regimen containing at least one antibiotic with in vitro activity against each of the bacteria causing a particular episode of pneumonia.

The CAUSE Advisory Board developed new institution-specific guidelines for the treatment of HAP based on the principles stated in the ATS/IDSA guidelines and our analysis of local microbiologic data. This evaluation was approved by our investigational review board. Patient consent was not deemed necessary.

One hundred fifteen episodes of pneumonia meeting inclusion criteria were identified. The data set included second pneumonias that developed in four patients during the same hospital admission as their first pneumonias. All patients were endotracheally intubated and placed on mechanical ventilation at the time of pneumonia onset. There were 194 isolates from respiratory tract cultures that met criteria for significant growth, 139 of which were Gram-negative organisms (Table 1 ). Eighty-one respiratory tract cultures (70%) were obtained by BAL; 32 cultures (28%) were obtained by tracheal aspirate. The source of respiratory tract culture was not recorded for two samples. Quantitative criteria were used to assess 106 of the cultures (92%), with the rest being evaluated semiquantitatively. The categorization of pneumonia episodes by primary service and time of onset is summarized in Figure 1 . The majority of patients who acquired pneumonia were on the trauma, surgery, or medicine critical-care services. Thirty-eight pneumonias were classified as early onset pneumonias, 71% of which occurred on the trauma service.

The most frequently identified pathogen was S aureus, which was isolated in 38% of cases. Of the 44 S aureus isolates identified, 22 isolates (50%) were resistant to oxacillin (MRSA). Nineteen of the MRSA isolates (86%) were cultured from late-onset pneumonias. The remaining isolates were from one patient who was transferred from a ventilator hospital and two trauma victims with no apparent risk factors for MRSA. The second-most-frequently encountered Gram-positive organism was S pneumoniae. Six of the seven S pneumoniae isolates were susceptible to penicillin, and one isolate was intermediate.

The most frequently identified Gram-negative bacteria were A baumannii and P aeruginosa. The antimicrobial susceptibilities for the Gram-negative isolates as a group are summarized in Table 2 . The most frequently active antibiotic was amikacin. Since piperacillin-tazobactam and cefepime are the two most frequently used β-lactams for HAP at our institution, we examined the antimicrobial susceptibilities for those isolates that were not susceptible to piperacillin-tazobactam or cefepime (Table 3 ). Both ciprofloxacin and gentamicin had relatively poor activity against isolates that were resistant to piperacillin-tazobactam or cefepime, while amikacin covered > 80% of these bacteria. As can be seen in Figure 2 , resistance to piperacillin-tazobactam among Gram-negative isolates became more likely as the length of hospital stay increased. The data were similar for cefepime-nonsusceptible bacteria (data not shown).

The coverage provided by various antibiotic combinations against the Gram-negative isolates is displayed in Table 4 . Combining amikacin with piperacillin-tazobactam, cefepime, or meropenem provided coverage against 96% of the Gram-negative bacteria.

Each episode of late-onset pneumonia was analyzed to determine the adequacy of various empiric regimens. These results are summarized in Table 5 . Either piperacillin-tazobactam or cefepime combined with vancomycin and amikacin would be anticipated to provide adequate initial therapy for 93% of the pneumonias.

The CAUSE Advisory Board developed new adult HAP guidelines using the principles stated in the ATS/IDSA guidelines that included empiric therapy recommendations based on our local microbiologic data. The following conclusions from the pathogen analysis were incorporated into the treatment recommendations: (1) MRSA coverage should be provided for all late-onset pneumonias; (2) resistance of Gram-negative organisms to piperacillin-tazobactam and cefepime is more common for isolates recovered ≥ 10 days of hospitalization; therefore, empiric regimens for pneumonias developing on days 5 to 9 (deemed “early-late” pneumonias) and pneumonias developing after day 9 (deemed “late-late” pneumonias) may differ; (3) adding ciprofloxacin does not significantly expand the empiric coverage offered by piperacillin-tazobactam or cefepime; (4) piperacillin-tazobactam, cefepime, and meropenem provide similar coverage of Gram-negative organisms; based on cost and resistance concerns, piperacillin-tazobactam and cefepime are the preferred β-lactam antibiotics for late-onset pneumonias; and (5) amikacin is the only agent that reliably covers Gram-negative organisms resistant to piperacillin-tazobactam or cefepime.

Our guidelines for initial therapy are displayed in Figure 3 . Recommendations for the treatment of early pneumonias with no risk factors for MDR organisms were adapted directly from the ATS/IDSA guidelines with antibiotic choices specific to our formulary. The ATS/IDSA guidelines recommend giving vancomycin plus two antibiotics targeting Gram-negative organisms for patients with risk factors for MDR pathogens, including those with late-onset pneumonia. Based on our data, the only antibiotic that reliably expanded the empiric Gram-negative coverage offered by piperacillin-tazobactam or cefepime was amikacin. However, many of our clinicians were concerned about the possible toxicities associated with aminoglycosides and wanted to add amikacin only when truly necessary. Since our analysis showed that most of the Gram-negative isolates cultured prior to hospital day 10 were sensitive to piperacillin-tazobactam and cefepime, adding amikacin to these patients did not appreciably increase the empiric coverage of pneumonias occurring on days 5 to 9. Therefore, we feel that using only one antibiotic targeting Gram-negative pathogens is an acceptable alternative for most of these patients. However, given the frequency of Gram-negative organisms resistant to piperacillin-tazobactam and cefepime recovered after hospital day 9, concurrent amikacin is recommended for all late-late pneumonias.

As can be seen in Figure 3, our institution-specific recommendations were integrated into a format similar to Figure 1 in the ATS/IDSA guidelines.3 Our guidelines also include a vancomycin dosing guide targeting trough levels of 15 to 20 μg/mL as recommended in the ATS/IDSA guidelines. In addition to this page, our four-panel institution-specific guidelines include panels that summarize the major principles of HAP treatment, recommend how to de-escalate antibiotic therapy, and instruct clinicians on how to dose and monitor amikacin. The entire guideline document can be viewed at http://www1.wfubmc.edu/NR/rdonlyres/60A92412–5A1D-498B-A84D-9644D815763E/0/HAP.pdf.

To our knowledge, this is the first published description of a process for incorporating local microbiologic data into institution-specific HAP guidelines. Because of the clinical benefit of providing adequate initial therapy to patients with HAP,1015 it is essential to start patients on empiric therapy that is most likely to cover the causative pathogen(s). Since the susceptibility of HAP pathogens can vary substantially among institutions, it is optimal to base empiric treatment recommendations on local susceptibility data. Unit-specific antibiograms can assist with this goal. However, antibiograms only provide the susceptibilities of a particular bacterial species to individual antibiotics. They do not indicate which antibiotics are active against those bacteria that are resistant to other antibiotics or the impact of combining various antimicrobial agents. Antibiograms usually include bacteria cultured from all body sites. Our investigation included only those cultures associated with HAP. This analysis allowed us to recommend initial treatment regimens that would have provided adequate therapy for > 90% of late-onset pneumonias at our institution. Prior to this evaluation, it was common for our prescribers to add ciprofloxacin to a β-lactam and vancomycin as empiric therapy for pneumonia in patients at risk for MDR pathogens. If we had not modified the ATS/IDSA guidelines based on our local microbiologic data, our guidelines would have continued to list ciprofloxacin as an option for these patients. Based on our analysis, we would predict that this combination would provide adequate empiric therapy for only 70% of our late-onset pneumonias.

Our guidelines differ from the ATS/IDSA guidelines in that we have divided the “late onset/risk of MDR pathogens” group of patients into two subcategories. Patients acquiring pneumonia on days 5 to 9 of hospitalization are deemed early-late pneumonias; those acquiring pneumonia after day 9 are deemed late-late pneumonias. Our guidelines recommend using only one antibiotic targeting Gram-negative organisms for most patients with early-late pneumonia. Some may argue that two antibiotics should be used to treat Gram-negative infections to either prevent the development of resistance or to provide synergistic activity that will improve patient outcomes. However, the available evidence, recently summarized in two meta-analyses,1617 does not support the usefulness of double Gram-negative therapy to achieve either of these objectives. Therefore, our guidelines recommend combining two Gram-negative antibiotics only for the purpose of expanding empiric coverage. We believe that our recommendations are consistent with the principles stated in the ATS/IDSA guidelines, in that they provide adequate empiric therapy and minimize toxicities and unnecessary antibiotic exposure. We encourage our clinicians to consider the patient’s history, including prior exposure to specific antibiotics, when selecting empiric therapy. This may lead to a choice of therapy different from those stated in our guidelines.

Our study has limitations. Our methodology did not allow a complete analysis of all risk factors for MDR organisms. This limited our ability to further refine our guidelines to target more specific patient populations. If patients were transferred from another hospital, we did not include the days of hospitalization at their previous institution when determining day of pneumonia onset. It is not known if including length of stay in previous hospitals would have altered our analysis. Further, since all of the pneumonias occurred in patients who were in the ICU or intermediate-care unit and on a ventilator, our results might not accurately represent the pathogens causing HAP in patients located on other units and/or not on a ventilator. However, pathogens appear to be similar for patients acquiring pneumonia while receiving or not receiving mechanical ventilation (D. Weber, MD, MPH; personal communication; August 2005).18 Since antibiotic resistance at our institution is more common in the ICU compared with non-critical care areas, we based our analysis on pathogens isolated from patients in the ICU, reasoning that this should provide adequate coverage for all patients in our hospital.

Our particular HAP guidelines may not be applicable to other institutions. Patient mix, antimicrobial sensitivity patterns, and methods of determining causative organisms can vary widely among hospitals. However, we believe that our process for incorporating local microbiologic data into institution-specific guidelines can be adapted to most health-care settings that have access to local microbiologic data.

Our guidelines were based on an evaluation of patients acquiring pneumonia during a 6-month period in 2004. Resistance patterns can change substantially over time due to both the emergence of resistant pathogens within the hospital and the increasing prevalence of resistant organisms in the community. Therefore, our guidelines will be revised in 2006 based on an ongoing analysis of HAP pathogens.

Providing adequate initial therapy for patients with HAP is associated with improved clinical outcomes. Selecting adequate empiric therapy requires an assessment of risk factors for MDR organisms and an understanding of the microbiology of local HAP pathogens. We describe our experience of using local microbiologic data to formulate institution-specific HAP guidelines. Our analysis of HAP pathogens focused on discovering which antibiotic combinations would be predicted to provide adequate initial therapy. Our data led us to divide the ATS/IDSA late onset/risk of MDR pathogens group of patients into two subcategories: early-late pneumonias and late-late pneumonias. Since ciprofloxacin added little to the empiric coverage provided by piperacillin- tazobactam and cefepime, our guidelines do not recommend that ciprofloxacin be used as empiric therapy. Instead, amikacin is recommended as a component of regimens targeting late-late pneumonias, since amikacin covers many bacteria not susceptible to piperacillin-tazobactam or cefepime. It is anticipated that our new guidelines will increase the percentage of patients initiated on adequate empiric therapy and thus improve outcomes for patients acquiring HAP at our institution.

Abbreviations: ATS = American Thoracic Society; CAUSE = Center for Antimicrobial Utilization, Stewardship, and Epidemiology; HAP = hospital-acquired pneumonia; IDSA = Infectious Diseases Society of America; MDR = multidrug resistant; MRSA = methicillin-resistant Staphylococcus aureus

The authors receive research funding from Cubist Pharmaceuticals (Drs. Williamson and Ohl); Theravance, Inc. (Dr. Bowton); Parion Sciences (Dr. Bowton); and Merck Pharmaceuticals (Dr. Ohl).

The authors are on the Speakers Bureau of Wyeth Pharmaceuticals (Drs. Beardsley and Bowton); Sanofi-Aventis Pharmaceuticals (Drs. Beardsley and Ohl); Pfizer Pharmaceuticals (Drs. Ohl and Karchmer); Cubist Pharmaceuticals (Dr. Karchmer); GlaxoSmithKline (Dr. Williamson); Ortho-McNeil Pharmaceuticals (Dr. Ohl); and Schering-Plough Pharmaceuticals (Dr. Ohl).

The authors are consultants for Wyeth Pharmaceuticals (Drs. Beardsley and Bowton), Parion Sciences (Dr. Bowton); Cubist Pharmaceuticals (Dr. Ohl); and Ortho-McNeil Pharmaceuticals (Drs. Ohl and Williamson).

Table Graphic Jump Location
Table 1. Pathogens Associated With HAP (n = 194)
* 

One isolate each of Enterobacter asburiae,Morganella morganii,Proteus vulgaris, Coagulase-negative Staphylococcus, Eikenella corrodens,Enterococcus faecium, and Burkholderia cepacia.

Figure Jump LinkFigure 1. Pneumonia by service. MCC = medical critical care; SUR = general surgery; TRA = trauma; NSG = neurosurgery; CTS = cardiothoracic surgery.Grahic Jump Location
Table Graphic Jump Location
Table 2. Susceptibilities of Gram-Negative Isolates (n = 139)
Table Graphic Jump Location
Table 3. Activity of Various Antibiotics Against Gram-Negative Isolates not Susceptible to Piperacillin-Tazobactam or Cefepime*
* 

Data are presented as No. (%). NA = not applicable.

Figure Jump LinkFigure 2. Susceptibility of Gram-negative isolates to piperacillin-tazobactam: influence of day of pneumonia onset.Grahic Jump Location
Table Graphic Jump Location
Table 4. Adequacy of Various Antibiotic Combinations Against All Gram-Negative Isolates (n = 139)*
* 

Data are presented as percentage susceptible to at least one antibiotic.

Table Graphic Jump Location
Table 5. Activity of Amikacin-Containing and Ciprofloxacin-Containing Regimens for Late-Onset Pneumonias
* 

No. (%) of episodes in which all pathogens were susceptible to at least one antibiotic contained in the regimen.

 

No. (%) of isolates susceptible to at least one antibiotic contained in the regimen.

Figure Jump LinkFigure 3. Institution-specific guideline for HAP (page 1). Amp = ampicillin; Pip-tazo = piperacillin-tazobactam; ID = infectious diseases; CrCl = creatinine clearance.Grahic Jump Location
Centers for Disease Control and Prevention. Guidelines for preventing healthcare-associated-pneumonia, 2003. Available at: www.cdc.gov/ncidod/hip/guide/CDCpneumo_guidelines.pdf; accessed October 7, 2005.
 
National Nosocomial Infections Surveillance System.. Data summary from January 1992 through June 2004.Am J Infect Control2004;32,470-485. [CrossRef] [PubMed]
 
American Thoracic Society and the Infectious Diseases Society of America.. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.Am J Respir Crit Care Med2005;171,388-416. [CrossRef] [PubMed]
 
Ibrahim, EH, Ward, S, Sherman, G, et al Experience with a clinical guideline for the treatment of ventilator-associated pneumonia.Crit Care Med2001;29,1109-1115. [CrossRef] [PubMed]
 
Hoo, GWS, Wen, YE, Nguyen, TV, et al Impact of clinical guidelines in the management of severe hospital-acquired pneumonia.Chest2005;128,2778-2787. [CrossRef] [PubMed]
 
Kollef, MH Inadequate antimicrobial treatment: an important determinant of outcome for hospitalized patients.Clin Infect Dis2000;31(Suppl 4),S131-S138. [PubMed]
 
Niederman, MS Appropriate use of antimicrobial agents: challenges and strategies for improvement.Crit Care Med2003;31,608-616. [CrossRef] [PubMed]
 
Ohl, CA Antimicrobial stewardship as a means to control drug resistant pathogens.Semin Infect Control2001;1,210-221
 
Horan, TC, Gaynes, RP Surveillance of nosocomial infections. Mayhall, CG eds.Hospital epidemiology and infection control 3rd ed.2004,1659-1702 Lippincott, Williams & Wilkens. Philadelphia, PA:
 
Kollef, MH, Sherman, G, Ward, S, et al Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients.Chest1999;115,462-474. [CrossRef] [PubMed]
 
Luna, CM, Vujajich, P, Niederman, MS, et al Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia.Chest1997;111,676-685. [CrossRef] [PubMed]
 
Rello, J, Gallego, M, Mariscal, D, et al The value of routine microbial investigation in ventilator-associated pneumoniaAm J Respir Crit Care Med1997;156,196-200. [PubMed]
 
Dupont, H, Mentec, H, Sollet, JP, et al Impact of appropriateness of initial antibiotic therapy on the outcome of ventilator-associated pneumonia.Intensive Care Med2001;27,355-362. [CrossRef] [PubMed]
 
Iregui, M, Ward, S, Sherman, G, et al Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia.Chest2002;122,262-268. [CrossRef] [PubMed]
 
Alvarez-Lerma, F Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. ICU-Acquired Pneumonia Study Group.Intensive Care Med1996;22,387-394. [CrossRef] [PubMed]
 
Paul, M, Benuri-Silbiger, I, Soares-Weiser, K, et al β-Lactam monotherapy versus β-lactam-aminoglycoside combination therapy for sepsis in immunocompetent patients: systematic review and meta-analysis of randomized trials.BMJ2004;328,668-672. [CrossRef] [PubMed]
 
Bliziotis, IA, Samonis, G, Vardakas, KZ, et al Effect of aminoglycoside and β-lactam combination therapy versus β-lactam monotherapy on the emergence of antimicrobial resistance: a meta-analysis of randomized, controlled trials.Clin Infect Dis2005;41,149-158. [CrossRef] [PubMed]
 
Ohi, H, Yanagihara, K, Miyazaki, Y, et al Hospital-acquired pneumonia in general wards of a Japanese tertiary hospital.Respirology2004;9,120-124. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. Pneumonia by service. MCC = medical critical care; SUR = general surgery; TRA = trauma; NSG = neurosurgery; CTS = cardiothoracic surgery.Grahic Jump Location
Figure Jump LinkFigure 2. Susceptibility of Gram-negative isolates to piperacillin-tazobactam: influence of day of pneumonia onset.Grahic Jump Location
Figure Jump LinkFigure 3. Institution-specific guideline for HAP (page 1). Amp = ampicillin; Pip-tazo = piperacillin-tazobactam; ID = infectious diseases; CrCl = creatinine clearance.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Pathogens Associated With HAP (n = 194)
* 

One isolate each of Enterobacter asburiae,Morganella morganii,Proteus vulgaris, Coagulase-negative Staphylococcus, Eikenella corrodens,Enterococcus faecium, and Burkholderia cepacia.

Table Graphic Jump Location
Table 2. Susceptibilities of Gram-Negative Isolates (n = 139)
Table Graphic Jump Location
Table 3. Activity of Various Antibiotics Against Gram-Negative Isolates not Susceptible to Piperacillin-Tazobactam or Cefepime*
* 

Data are presented as No. (%). NA = not applicable.

Table Graphic Jump Location
Table 4. Adequacy of Various Antibiotic Combinations Against All Gram-Negative Isolates (n = 139)*
* 

Data are presented as percentage susceptible to at least one antibiotic.

Table Graphic Jump Location
Table 5. Activity of Amikacin-Containing and Ciprofloxacin-Containing Regimens for Late-Onset Pneumonias
* 

No. (%) of episodes in which all pathogens were susceptible to at least one antibiotic contained in the regimen.

 

No. (%) of isolates susceptible to at least one antibiotic contained in the regimen.

References

Centers for Disease Control and Prevention. Guidelines for preventing healthcare-associated-pneumonia, 2003. Available at: www.cdc.gov/ncidod/hip/guide/CDCpneumo_guidelines.pdf; accessed October 7, 2005.
 
National Nosocomial Infections Surveillance System.. Data summary from January 1992 through June 2004.Am J Infect Control2004;32,470-485. [CrossRef] [PubMed]
 
American Thoracic Society and the Infectious Diseases Society of America.. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.Am J Respir Crit Care Med2005;171,388-416. [CrossRef] [PubMed]
 
Ibrahim, EH, Ward, S, Sherman, G, et al Experience with a clinical guideline for the treatment of ventilator-associated pneumonia.Crit Care Med2001;29,1109-1115. [CrossRef] [PubMed]
 
Hoo, GWS, Wen, YE, Nguyen, TV, et al Impact of clinical guidelines in the management of severe hospital-acquired pneumonia.Chest2005;128,2778-2787. [CrossRef] [PubMed]
 
Kollef, MH Inadequate antimicrobial treatment: an important determinant of outcome for hospitalized patients.Clin Infect Dis2000;31(Suppl 4),S131-S138. [PubMed]
 
Niederman, MS Appropriate use of antimicrobial agents: challenges and strategies for improvement.Crit Care Med2003;31,608-616. [CrossRef] [PubMed]
 
Ohl, CA Antimicrobial stewardship as a means to control drug resistant pathogens.Semin Infect Control2001;1,210-221
 
Horan, TC, Gaynes, RP Surveillance of nosocomial infections. Mayhall, CG eds.Hospital epidemiology and infection control 3rd ed.2004,1659-1702 Lippincott, Williams & Wilkens. Philadelphia, PA:
 
Kollef, MH, Sherman, G, Ward, S, et al Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients.Chest1999;115,462-474. [CrossRef] [PubMed]
 
Luna, CM, Vujajich, P, Niederman, MS, et al Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia.Chest1997;111,676-685. [CrossRef] [PubMed]
 
Rello, J, Gallego, M, Mariscal, D, et al The value of routine microbial investigation in ventilator-associated pneumoniaAm J Respir Crit Care Med1997;156,196-200. [PubMed]
 
Dupont, H, Mentec, H, Sollet, JP, et al Impact of appropriateness of initial antibiotic therapy on the outcome of ventilator-associated pneumonia.Intensive Care Med2001;27,355-362. [CrossRef] [PubMed]
 
Iregui, M, Ward, S, Sherman, G, et al Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia.Chest2002;122,262-268. [CrossRef] [PubMed]
 
Alvarez-Lerma, F Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. ICU-Acquired Pneumonia Study Group.Intensive Care Med1996;22,387-394. [CrossRef] [PubMed]
 
Paul, M, Benuri-Silbiger, I, Soares-Weiser, K, et al β-Lactam monotherapy versus β-lactam-aminoglycoside combination therapy for sepsis in immunocompetent patients: systematic review and meta-analysis of randomized trials.BMJ2004;328,668-672. [CrossRef] [PubMed]
 
Bliziotis, IA, Samonis, G, Vardakas, KZ, et al Effect of aminoglycoside and β-lactam combination therapy versus β-lactam monotherapy on the emergence of antimicrobial resistance: a meta-analysis of randomized, controlled trials.Clin Infect Dis2005;41,149-158. [CrossRef] [PubMed]
 
Ohi, H, Yanagihara, K, Miyazaki, Y, et al Hospital-acquired pneumonia in general wards of a Japanese tertiary hospital.Respirology2004;9,120-124. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

CHEST Journal Articles
Hospital-Acquired Pneumonia*: Risk Factors, Microbiology, and Treatment
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543