383. Applicability of IDSA/ATS Recommendations for HAP and HCAP and Impact of Sputum Cultures on De-Escalation Therapy in a Non-Intensive Care Unit Setting
Session: Poster Session: Hospital-acquired and Transplant Infections
Friday, October 30, 2009: 12:00 AM
Room: Poster Hall A
Background: 2004 IDSA/ATS guidelines for the management of hospital-acquired (HAP), ventilator-associated and healthcare-associated pneumonia (HCAP) in adults recommend initiation of early broad spectrum antimicrobial therapy (AT), followed by de-escalation based on lower respiratory tract culture (LRTC) and the clinical response of the patient. Collection of a LRTC can be challenging and how sputum microbiology influences clinical decisions is unclear. In addition, controversy exists as to whether improved outcomes are seen with combination therapy vs. monotherapy.
Methods: Patients treated for HAP and HCAP in a non-ICU setting at a large US teaching hospital from December 2008 to May 2009 were prospectively identified. Variables determined included age, sex, length of stay, whether LRTC had been ordered and/or obtained, culture results, length, type and number of AT, whether de-escalation therapy (DT) occurred and if LRTC had an impact on DT.
Results: 98 patients were prospectively identified, 79% with HCAP and 21% with HAP. 58% of pts with HCAP and 67% of patients with HAP had LRTC ordered within the first 48 hours of AT for pneumonia. Of these LRTC, 35/59 (59%) were obtained. Overall, 36% of patients had a LRTC available, and a pathogen was identified in 18/98 (18%). Patients received an average of 2.6 antimicrobials and average length of therapy was 8.1 days. DT occurred in 43% of patients for whom a LRTC was available, compared to 40% of patients without LRTC. However, DT of antimicrobial therapy occurred in 61% of patients for whom a pathogen was identified in LRTC, compared to 36% of patients for without a LRTC pathogen.
Conclusion: De-escalation of antimicrobial therapy occurred more frequently when LRTC identified a respiratory pathogen. Guidelines that recommend empiric broad spectrum coverage with streamlining based on cultures may not be realistic in the non-ICU setting and may lead to excess AT.
Tara Babu, MD1, Roy Guharoy, PharmD, MBA2, Elizabeth Radigan, PharmD3, Gail Scully, MD, MPH3 and  E. Radigan, None..
T. Babu, None..
R. Guharoy, None..
G. Scully, None., (1)Univ. of Massachusetts Sch. of Med., Worcester, MA, (2)UMass Memorial Health Care, Worcester, MA, (3)UMass Mem. Med. Ctr., Worcester, MA