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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 Nov; 57(10):1373-83.CI

Abstract

BACKGROUND

Optimal empiric therapy for hospitalized patients with healthcare-associated pneumonia (HCAP) 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 < .001) in HCAP patients than in CAP patients, including Staphylococcus aureus (11.5% vs 0.8%, P < .001); methicillin-resistant S. aureus (6.9% vs 0%, P = .003); Enterobacteriaceae (7.8% vs 2.4%, P = .037); and Pseudomonas aeruginosa (6.9% vs 0.8%, P = .01). Using the proposed algorithm, HCAP patients with ≥2 MDR risk factors, one of which was severity of illness (n = 170), vs HCAP patients with 0-1 risk factor (n = 151) had a significantly higher frequency of MDR pathogens (27.1% vs 2%, P < .001). In total, 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. Thirty-day mortality was significantly higher for HCAP than for CAP (13.7% vs 5.6%, P = .017), but among HCAP patients with 0-1 MDR risk factor, mortality was lower than with ≥2 MDR risk factors (8.6% vs 18.2%, P = .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.

CLINICAL TRIALS REGISTRATION

Japan Medical Association Center for Clinical Trials, JMA-IIA00054.

Authors+Show Affiliations

Department of Respiratory Medicine, National Hospital Organization, Mie National Hospital, Tsu.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Multicenter Study
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

23999080

Citation

Maruyama, Takaya, et al. "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." Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America, vol. 57, no. 10, 2013, pp. 1373-83.
Maruyama T, Fujisawa T, Okuno M, et al. 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;57(10):1373-83.
Maruyama, T., Fujisawa, T., Okuno, M., Toyoshima, H., Tsutsui, K., Maeda, H., Yuda, H., Yoshida, M., Kobayashi, H., Taguchi, O., Gabazza, E. C., Takei, Y., Miyashita, N., Ihara, T., Brito, V., & Niederman, M. S. (2013). 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. Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America, 57(10), 1373-83. https://doi.org/10.1093/cid/cit571
Maruyama T, et al. 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;57(10):1373-83. PubMed PMID: 23999080.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - 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. AU - Maruyama,Takaya, AU - Fujisawa,Takao, AU - Okuno,Masataka, AU - Toyoshima,Hirokazu, AU - Tsutsui,Kiyoyuki, AU - Maeda,Hikaru, AU - Yuda,Hisamichi, AU - Yoshida,Masamichi, AU - Kobayashi,Hiroyasu, AU - Taguchi,Osamu, AU - Gabazza,Esteban C, AU - Takei,Yoshiyuki, AU - Miyashita,Naoyuki, AU - Ihara,Toshiaki, AU - Brito,Veronica, AU - Niederman,Michael S, Y1 - 2013/09/02/ PY - 2013/9/4/entrez PY - 2013/9/4/pubmed PY - 2014/5/23/medline KW - appropriate therapy KW - empiric antibiotic therapy KW - healthcare-associated pneumonia KW - multidrug resistance KW - risk factors SP - 1373 EP - 83 JF - Clinical infectious diseases : an official publication of the Infectious Diseases Society of America JO - Clin Infect Dis VL - 57 IS - 10 N2 - BACKGROUND: Optimal empiric therapy for hospitalized patients with healthcare-associated pneumonia (HCAP) 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 < .001) in HCAP patients than in CAP patients, including Staphylococcus aureus (11.5% vs 0.8%, P < .001); methicillin-resistant S. aureus (6.9% vs 0%, P = .003); Enterobacteriaceae (7.8% vs 2.4%, P = .037); and Pseudomonas aeruginosa (6.9% vs 0.8%, P = .01). Using the proposed algorithm, HCAP patients with ≥2 MDR risk factors, one of which was severity of illness (n = 170), vs HCAP patients with 0-1 risk factor (n = 151) had a significantly higher frequency of MDR pathogens (27.1% vs 2%, P < .001). In total, 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. Thirty-day mortality was significantly higher for HCAP than for CAP (13.7% vs 5.6%, P = .017), but among HCAP patients with 0-1 MDR risk factor, mortality was lower than with ≥2 MDR risk factors (8.6% vs 18.2%, P = .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. CLINICAL TRIALS REGISTRATION: Japan Medical Association Center for Clinical Trials, JMA-IIA00054. SN - 1537-6591 UR - https://www.unboundmedicine.com/medline/citation/23999080/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_ L2 - https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/cit571 DB - PRIME DP - Unbound Medicine ER -