Implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care: An observational, multicentre cohort study.
Open accessAbstract
Background The American Thoracic Society and Infectious Diseases Society of America provide guidelines for management of hospital-acquired, ventilator-associated, and health-care-associated pneumonias, consisting of empirical antibiotic regimens for patients at risk for multidrug-resistant pathogens. We aimed to improve compliance with these guidelines and assess outcomes.Methods We implemented a performance-improvement initiative in four academic medical centres in the USA with protocol-based education and prospective observation of outcomes. Patients were assessed for severity of illness and followed up until death, hospital discharge, or day 28. We included patients in intensive-care units who were at risk for multidrug-resistant pneumonia and were treated empirically.Findings 303 patients at risk for multidrug-resistant pneumonia were treated empirically, and prescribed treatment was guideline compliant in 129 patients and non-compliant in 174 patients. 44 (34%) patients died before 28 days in the compliance group and 35 (20%) died in the non-compliance group. Five patients in the compliance group and seven in the non-compliance group were lost to follow-up after day 14. Kaplan-Meier estimated survival to 28 days was 65% in the compliance group and 79% in the non-compliance group (p=0·0042). This difference persisted after adjustment for severity of illness. Median length of stay and duration of mechanical ventilation did not differ between groups. Compliance failures included non-use of dual treatment for Gram-negative pathogens in 154 patients and absence of meticillin-resistant Staphylococcus aureus coverage in 24 patients. For patients in whom pathogens were subsequently identified, empirical treatment was active in 79 (81%) of 97 of patients receiving compliant therapy compared with 109 (85%) of 128 of patients receiving non-compliant therapy.Interpretation Because adherence with empirical treatment was associated with increased mortality, we recommend a randomised trial be done before further implementation of these guidelines.Funding Pfizer, US Medical.
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In documented MRSA infections, delays of more than 24-48 hours before antibiotic administration are associated with increased mortality in some studies but not in others.
“Among patients with documented MRSA infections, delays of > 24–48 h until antibiotic administration are associated with increased mortality in some studies [143–147], but not in others [148–154].”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [151]
In undifferentiated patients with pneumonia or sepsis, broad-spectrum regimens active against MRSA are associated with higher mortality, especially in patients without MRSA.
“Among undifferentiated patients with pneumonia or sepsis, broad-spectrum regimens including agents active against MRSA were associated with higher mortality, particularly among patients without MRSA [137, 151, 155, 156].”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [151]
Overly broad antibiotics are associated with similarly poor outcomes as inappropriately narrow antibiotics.
“Prior investigations suggest that overly broad antibiotics are associated with similarly poor outcomes as inappropriately narrow antibiotics.”
From Trends in empiric broad-Spectrum antibiotic use for suspected community-onset Sepsis in US hospitals (2024) · cites this paper as [41]
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- Authors
- Kett, D. H., Cano, E., Quartin, A. A., Mangino, J. E., Zervos, M. J., Peyrani, P., Cely, C. M., Ford, K. D., Scerpella, E. G., & Ramirez, J. A.
- Affiliations
- University of Miami (US)
- The Ohio State University (US)
- Henry Ford Health (US)
- University of Louisville (US)
- Pfizer (United States) (US)
- Corresponding author
- Kett, Daniel H
- Venue
- The Lancet Infectious Diseases
- Publisher
- Elsevier BV
- Published
- 2011-03
- Volume
- 11
- Issue
- 3
- Pages
- 181-189
- ISSN
- 1473-3099 (ISSN-L)
- OpenAlex
- W2137837217
- Semantic Scholar
- f9cf000caf5d5d18a464d526d6b2369891b26346
- Cited by
- 235
- References
- 36
- Citations by year
- 2026: 3 · 2025: 9 · 2024: 13 · 2023: 5 · 2022: 7 · 2021: 6 · 2020: 14 · 2019: 15 · 2018: 12 · 2017: 20 · 2016: 17 · 2015: 16 · 2014: 30 · 2013: 23 · 2012: 25
- FWCI
- 25.26
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Lancet Infectious Diseases (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Nosocomial Infections in ICU
- Life Sciences › Immunology and Microbiology › Applied Microbiology and Biotechnology › Antibiotic Use and Resistance
- Health Sciences › Medicine › Epidemiology › Pneumonia and Respiratory Infections
- Keywords
- empirical antibiotic therapy, guideline adherence, intensive care, ventilator-associated pneumonia, nosocomial pneumonia, healthcare-associated pneumonia, 28-day mortality, performance improvement, Gram-negative pathogens, methicillin-resistant Staphylococcus aureus, length of hospital stay, mechanical ventilation duration
- MeSH terms
- Adolescent, Adult, Cross Infection, Humans, Intensive Care Units, Middle Aged, Societies, Medical, Cohort Studies, Treatment Outcome, Practice Guidelines as Topic, Pneumonia, Bacterial, Drug Resistance, Multiple, Bacterial, Pneumonia, Ventilator-Associated, Young Adult
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