195. De-escalation of Antimicrobial Treatment of Healthcare-Associated Pneumonia Within the Veterans Healthcare System
Session: Poster Abstract Session: Antimicrobial Stewardship: Current State and Future Opportunities
Thursday, October 8, 2015
Room: Poster Hall
  • IDSA_SpectrumScore_#195_2015_Final_.png (186.6 kB)
  • Background:

    De-escalation of antimicrobial therapy is an important component of antimicrobial stewardship. Multi-centered reports of de-escalation practice are limited.  We applied a method to quantitatively measure antimicrobial de-escalation utilizing electronic medication administration data based on the spectrum of activity for antimicrobial therapy. We examined the de-escalation prevalence and characterized de-escalation in patients hospitalized with healthcare-associated pneumonia (HCAP).


    This was a retrospective cohort study performed in patients hospitalized between 5 and 14 days with HCAP in acute wards in 119 VA facilities. Patients who received antimicrobials for ≥3 days during 2008-2011 were included. The method was applied at the patient level to measure de-escalation on day 4 of hospitalization, and was expressed in aggregate and facility-level proportions. Logistic regression was used to assess variables associated with de-escalation. Odds ratios with 95% confidence intervals were reported.


    Among 9319 patients, the de-escalation rate was 28.3% (95% CI 27.4%, 29.2%) which varied six-fold across facilities [median (IQR) facility-level de-escalation rate 29.1% (21.7%, 35.6%)]. Variables independently associated with de-escalation included: initial broad-spectrum therapy [OR 1.5, 95% CI 1.4-1.5 for each 10% increase in spectrum], collection of respiratory tract cultures [OR 1.1, 95% CI 1.0-1.2], and care in higher complexity facilities [OR 1.3, 95% CI 1.1-1.6]. Respiratory tract cultures were collected in 35.3% (95% CI 32.7%, 37.7%) of patients.  For the cohort subset admitted in 2011 (n=2366), a patient’s probability of being de-escalated was positively associated with admission to a facility with de-escalation policy (OR 1.4, 95% CI 1.1-1.8, P=0.002) or an IV to PO policy (OR 1.3. 95% CI 1.1-1.5, P=0.012) as determined in a 2012 VA-wide stewardship survey.


    De-escalation of therapy was limited and varied substantially across facilities.  De-escalation was associated with collection of respiratory tract cultures, receipt of care in facilities with higher levels of complexity, and was performed more frequently in facilities with policies governing de-escalation or IV to PO conversion.

    Karl Madaras-Kelly, PharmD., MPH, VA Med. Ctr., Coll. of Pharmacy, Idaho State University, Boise, ID, Makoto Jones, MD, MS, Internal Medicine, University of Utah School of Medicine Division of Epidemiology, Salt Lake City, UT, Richard Remington, MS, VA Med. Ctr.,& Quantified Inc., Boise, ID, Christina Caplinger, PharmD, Vet. Affairs Medical Center, Boise, ID & Coll. of Pharmacy, Idaho State Univ.. Meridian, ID. USA, Boise, ID, Benedikt Huttner, MD, MS, Infection Control Program, Geneva University Hospitals, Geneva, Switzerland, Barbara Jones, MD, University of Utah, Salt Lake City, UT and Matthew Samore, MD, FSHEA, University of Utah School of Medicine, Division of Epidemiology, Salt Lake City, UT


    K. Madaras-Kelly, None

    M. Jones, None

    R. Remington, None

    C. Caplinger, None

    B. Huttner, None

    B. Jones, None

    M. Samore, None

    Findings in the abstracts are embargoed until 12:01 a.m. PDT, Wednesday Oct. 7th with the exception of research findings presented at the IDWeek press conferences.