191. Decreased Compliance of a Ventilator Associated Pneumonia (VAP) Clinical Pathway Results in Inappropriate Antibiotic Utilization and Increasing Mortality
Session: Poster Abstract Session: Antibiotic Stewardship
Friday, October 21, 2011
Room: Poster Hall B1
Background: Our hospital’s intensive care units implemented a clinical pathway (CP) in 2006 for the empiric treatment of VAP based on unit specific antibiograms and pharmacodynamic concepts. The CP successfully increased appropriate antibiotic therapy and reduced infection-related (IR) mortality, length of stay, and superinfection rates compared with a historic control. Recently, the CP was changed from a mandatory protocol to a guideline in line with new hospital policies, resulting in a reduction in CP compliance to 44%. Herein, we compare the outcomes of patients treated with the CP with those treated by provider discretion (PD).

Methods: This was a retrospective, observation study comparing antibiotic utilization and clinical outcomes between CP and PD cohorts. The CP treated group included all culture positive VAP patients treated with the CP from Sept. 2006-Aug. 2007 and Sept. 2009-April 2010 (n=100). PD patients included patients treated off the CP between Sept. 2009-April 2010 (n=36).

Results: Most patients had late onset VAP and were similar in age, gender, and co-morbidities between groups. APACHE II was 18.8 ± 8.2 and 17.3 ± 5.5 (p=0.416) for CP and PD groups, respectively. Staphylococcus aureus (15% MRSA) and Pseudomonas aeruginosa were the most common pathogens. The proportion of patients with appropriate antibiotics within 24 hours of VAP identification was greater in the CP (74%) vs. PD group (13%, p=<0.001). Time to appropriate therapy was faster for CP patients [0.65 ± 0.89 vs. 1.29 ± 1.36 days (p=0.03)].  Triple antibiotic coverage was received in 77% of CP group vs. only 2.8% of PD patients (<0.001). IR-mortality was 15% and 22.2%, (p=0.464), respectively; however, in patients with APACHE II ≥ 20, IR-mortality was 15.6% and 40% (p=0.099) for CP and PD treated patients. Finally, a greater proportion of CP patients were de-escalated off anti-pseudomonal beta-lactams (75.8%) when not necessary vs. PD patients (33.3%, p=0.006).

Conclusion: A VAP CP provides more appropriate antibiotic therapy, improves de-escalation, and results in improved outcomes among the sickest patients. These data highlight the importance of continuing education after CP implementation to ensure compliance and maximize stewardship goals.

Subject Category: N. Hospital-acquired and surgical infections, infection control, and health outcomes including general public health and health services research

Ashley Wilde, Pharm.D.1, Michael Nailor, Pharm.D.1,2, David Nicolau, PharmD, FCCP, FIDSA1,3 and Joseph L. Kuti, Pharm.D.3, (1)Hartford Hospital, Hartford, CT, (2)University of Connecticut School of Pharmacy, Storrs, CT, (3)Center for Anti-Infective Research and Development, Hartford, CT


A. Wilde, None

M. Nailor, Astellas: Consultant and Speaker's Bureau, Consulting fee and Speaker honorarium
Forrest Pharmaceuticals: Speaker's Bureau, Speaker honorarium

D. Nicolau, None

J. L. Kuti, None

Findings in the abstracts are embargoed until 12:01 a.m. EST Thursday, Oct. 20 with the exception of research findings presented at IDSA press conferences.