978. Description of Practice and Outcomes in Healthcare-associated Pneumonia without a Microbiologic Diagnosis in Non-ventilated Patients
Session: Poster Abstract Session: Stewardship: Implementing Programs
Friday, October 4, 2013
Room: The Moscone Center: Poster Hall C
Posters
  • hcap_final.pdf (359.0 kB)
  • Background: Patients with health care-associated pneumonia (HCAP) are typically started on empiric broad-spectrum (BS) antibiotics.  Limited data exists on how to de-escalate antibiotics if a microbiologic diagnosis is never made. 

    Methods: We retrospectively identified hospitalized patients treated for HCAP at the Roudebush VAMC between 1/1/2011 and 12/31/2012.  All cases met the definition of HCAP: 1) a new radiographic infiltrate, 2) signs/symptoms of pneumonia, and 3) at least one risk factor for a multidrug-resistant (MDR) pathogen.  Patients receiving mechanical ventilation at the time of diagnosis were excluded.  BS therapy was defined as a combination of anti-pseudomonal and anti-MRSA antibiotics.  De-escalation involved a switch to or discontinuation of an agent resulting in a narrower spectrum of coverage.

     

    Results: A total of 90 patients were included in the analysis.  The mean age was 70 years; 88 (98%) were men.  Blood cultures were obtained from 77 patients (86%); sputum cultures were obtained from 35 (39%), and bronchoalveolar lavage was performed in 2(2%).   The sputum specimen was graded as fair in 71% and good in 29%.  Of patients with a pathogen identified, 7/20 (35%) were MDR.  Overall, 70 patients (78%) had no pathogen identified.

    The median duration of total antibiotics was 10 days (IQR 8-12).  Antibiotics were de-escalated in 60/68 (88%) of cases who were started on BS therapy.  The median time to de-escalation was 3 days (IQR 2-4).

    De-escalation was performed in 47/54 (87%) of patients without a pathogen identified.  The narrower regimen was parenteral in 8 (17%) and oral in 39 (83%).  Among patients without a microbiologic diagnosis, vancomycin was more commonly stopped when the MRSA nasal-swab was negative instead of positive (71% vs. 17%, p<0.01).   Compared to other patients started on BS antibiotics, patients without a microbiologic diagnosis who were de-escalated had comparable rates of mortality and readmission at one-month: mortality 13% vs. 11%, readmission 20% vs. 21%. 

     

    Conclusion:   A microbiologic diagnosis was infrequently made in cases of HCAP.  In the absence of a microbiologic diagnosis, physicians safely de-escalated antibiotic therapy.  The effectiveness of this approach may reflect low rates of antibiotic resistance in the study cohort.

    Mary Eckerle, Indiana University School of Medicine, Indianapolis, IN and Daniel Livorsi, MD, Medicine, Indiana University School of Medicine, Indianapolis, IN

    Disclosures:

    M. Eckerle, None

    D. Livorsi, None

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