PURPOSE: Multiple guidelines exist to aid clinicians in choosing antibiotic regimens in severe community-acquired pneumonia (SCAP). Our goal was to asses the impact of following these guidelines on the duration of mechanical ventilation (MV).
METHODS: We reviewed the records of patients needing MV who participated in a multicenter, prospective registry of SCAP. We compared the duration of MV in subjects who received antibiotics in accordance with the current guidelines of the Infectious Disease Society of America (IDSA+) to those who did not (IDSA-). We recorded information regarding multiple confounders including: demographics, co-morbidities (HIV, malignancy, diabetes), process of care (time to: antibiotics, blood cultures, and pulse oximetry; adequacy of antibiotics), infection characteristics (pathogen, presence of either bacteremia or empyema), & severity of illness (APACHE II, presence of shock and/or acute renal failure). Because we focused on duration of MV we restricted the analysis to patients who survived their ICU stay.
RESULTS: The final cohort included 199 subjects and Streptococcus pneumoniae was the most frequent pathogen. In 40% of cases antibiotics were not in accordance with IDSA recommendations. At baseline there were few differences between the two groups as a function of guideline adherence. In unadjusted analysis, the duration of MV was longer in persons given IDSA-treatment regimens (11 days vs. 10 days). In a multivariate Cox proportional hazard model, two variables were independently associated with greater durations of MV: development of acute renal failure (Hazard Ratio [HR] 1.47, 95% CI: 1.02-2.12) and prescription of an IDSA non-compliant regimen (HR 1.40, 95% CI: 1.02-1.93). Adjusted analysis indicated that patients not receiving a regimen consistent with IDSA guidelines spent an added 3 days on MV. Excluding the immunosuppressed subjects from the analysis (n=17) did not alter our findings.
CONCLUSION: Failure to follow formal antibiotic recommendations for the treatment of SCAP increases the need for continuing MV.
CLINICAL IMPLICATIONS: Given the costs associated with MV, enhanced guideline compliance represents a means for both improving outcomes and enhancing resource utilization in the ICU.
DISCLOSURE: Andrew Shorr, None.