Hospital-acquired pneumonia (HAP) results in considerable morbidity and mortality in critically ill patients and is difficult to distinguish from non-infectious conditions with similar signs and symptoms. Liberal use of antibiotics increases antibiotic resistance and superinfection and is costly. We hypothesized that a systematic approach to HAP management will promote appropriate use of antibiotics and improve patient outcomes.
Overall Study Design: Prospective, before-and-after assessment. To detect a clinically significant difference in duration of antibiotic therapy of three days, we targeted a sample size of 160 patients. This study was approved by the Research Ethics Board. Phase I: Observation of current practice. Inclusion criteria: MSICU patients hospitalized for >48 hours and a reasonable suspicion of new HAP. Exclusion criteria: Colonized lung transplant or already receiving treatment for HAP. We collected demographics, previous antibiotic use, risk factors, duration of therapy, length of stay, sequential clinical pulmonary infection scores (CPIS), antibiotics prescribed, and pathogens cultured. Phase II: Development of management guideline. We reviewed relevant literature and studies and consulted experts in respiratory, infectious disease, and ICU medicine as well as nursing and allied health clinicians. Data from Phase I was used to optimize the guideline. Phase III: Implementation of guideline (in progress) Phase IV: Evaluation of guideline (autumn 2004).
Phase I: Of patients treated, empiric therapy was prescribed in 85.5% and therapy was adequate in 75% of cases. The mean duration of therapy was 8.3 ± 4.8 days. Development of a second HAP and respiratory superinfection occurred in 12.5% and 7.5% of patients respectively. Initial CPIS scores of > 6 occurred in 23% of patients. Phase II: A guideline was designed which included a tool for decision-making regarding antibiotic therapy (the CPIS), guidelines for selection of empiric antibiotics and structured reassessment.
A hospital-specific HAP management guideline can be developed using a multi-disciplinary approach. Site-specific observations can be used to optimize the guideline.
Ongoing HAPI study will evaluate the impact of the management guideline on antibiotic usage and patient outcomes.
O. Fernandes, None.