Karl Madaras-Kelly1, Makoto Jones2, Richard Remington3, Christina M Caplinger4, Benedikt Huttner5, Barbara Jones6, Matthew Samore2. 1. Boise Veterans Affairs Medical Center, T111, 500 W. Fort Street, Boise, ID 83702, USA College of Pharmacy, Idaho State University, Meridian, ID, USA kmk@pharmacy.isu.edu. 2. George E. Whalen Veterans Affairs Medical Center, Salt Lake City, UT, USA Division of Epidemiology, University of Utah, Salt Lake City, UT, USA. 3. Boise Veterans Affairs Medical Center, T111, 500 W. Fort Street, Boise, ID 83702, USA Quantified Inc., Boise, ID, USA. 4. Boise Veterans Affairs Medical Center, T111, 500 W. Fort Street, Boise, ID 83702, USA College of Pharmacy, Idaho State University, Meridian, ID, USA. 5. Division of Infectious Diseases and Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland. 6. George E. Whalen Veterans Affairs Medical Center, Salt Lake City, UT, USA Division of Pulmonology and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA.
Abstract
OBJECTIVES: The objective of this study was to measure quantitatively antimicrobial de-escalation utilizing electronic medication administration data based on the spectrum of activity for antimicrobial therapy (i.e. spectrum score) to identify variables associated with de-escalation in a nationwide healthcare system. METHODS: A retrospective cohort study of patients hospitalized for healthcare-associated pneumonia was conducted in Veterans Affairs Medical Centers (n = 119). Patients hospitalized for healthcare-associated pneumonia on acute-care wards between 5 and 14 days who received antimicrobials for ≥ 3 days during calendar years 2008-11 were evaluated. The spectrum score method was applied at the patient level to measure de-escalation on day 4 of hospitalization. De-escalation was expressed in aggregate and facility-level proportions. Logistic regression was used to assess variables associated with de-escalation. ORs with 95% CIs were reported. RESULTS: Among 9319 patients, the de-escalation proportion was 28.3% (95% CI 27.4-29.2), which varied 6-fold across facilities [median (IQR) facility-level de-escalation proportion 29.1% (95% CI 21.7-35.6)]. Variables 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 from 35.3% (95% CI 32.7-37.7) of patients. CONCLUSIONS: De-escalation of antimicrobial therapy was limited and varied substantially across facilities. De-escalation was associated with respiratory tract culture collection and treatment in a high complexity-level facility.
OBJECTIVES: The objective of this study was to measure quantitatively antimicrobial de-escalation utilizing electronic medication administration data based on the spectrum of activity for antimicrobial therapy (i.e. spectrum score) to identify variables associated with de-escalation in a nationwide healthcare system. METHODS: A retrospective cohort study of patients hospitalized for healthcare-associated pneumonia was conducted in Veterans Affairs Medical Centers (n = 119). Patients hospitalized for healthcare-associated pneumonia on acute-care wards between 5 and 14 days who received antimicrobials for ≥ 3 days during calendar years 2008-11 were evaluated. The spectrum score method was applied at the patient level to measure de-escalation on day 4 of hospitalization. De-escalation was expressed in aggregate and facility-level proportions. Logistic regression was used to assess variables associated with de-escalation. ORs with 95% CIs were reported. RESULTS: Among 9319 patients, the de-escalation proportion was 28.3% (95% CI 27.4-29.2), which varied 6-fold across facilities [median (IQR) facility-level de-escalation proportion 29.1% (95% CI 21.7-35.6)]. Variables 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 from 35.3% (95% CI 32.7-37.7) of patients. CONCLUSIONS: De-escalation of antimicrobial therapy was limited and varied substantially across facilities. De-escalation was associated with respiratory tract culture collection and treatment in a high complexity-level facility.
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