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Antimicrobial Therapy Escalation and Hospital Mortality Among Patients with HCAP: A Single Center Experience

¹School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA ²EviMed Research Group, LLC, Goshen, MA ³Washington Hospital Center, Washington, DC ⁴Barnes-Jewish Hosp, St Louis, MO ⁵Ortho-McNeil Janssen Scientific Affairs, LLC, Raritan, NJ

Marya{at}EviMedGroup.org

Abstract

BackgroundPatients 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.

MethodsWe 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.

ResultsOf 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.

ConclusionAmong 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.

Key Words: pneumonia • mortality • antibiotics • hospital • outcomes • resistance