Takaya Maruyama1, Takao Fujisawa2, Tadashi Ishida3, Akihiro Ito3, Yoshitaka Oyamada4, Kazuyuki Fujimoto4, Masamichi Yoshida5, Hikaru Maeda5, Naoyuki Miyashita6, Hideaki Nagai7, Yoshifumi Imamura8, Nobuaki Shime9, Shoji Suzuki10, Masaru Amishima11, Futoshi Higa12, Hiroyasu Kobayashi13, Shigeru Suga2, Kiyoyuki Tsutsui1, Shigeru Kohno8, Veronica Brito14, Michael S Niederman15. 1. Department of Respiratory Medicine, National Hospital Organization, Mie National Hospital, Tsu. 2. Department of Pediatrics, National Hospital Organization, Mie National Hospital, Tsu. 3. Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Okayama. 4. Department of Respiratory Medicine, National Hospital Organization, Tokyo Medical Center, Meguro-ku. 5. Department of Respiratory Medicine, Mie Prefectural General Medical Center, Yokkaichi. 6. Department of Medicine, Kawasaki Medical School, Kurashiki, Okayama. 7. Center for Pulmonary Diseases, National Hospital Organization, Tokyo National Hospital, Kiyose-shi. 8. Second Department of Internal Medicine, Nagasaki University School of Medicine. 9. Department of Emergency and Critical Care Medicine, Institute of Biomedical and Health Sciences, Hiroshima University Advanced Emergency and Critical Care Center, Hiroshima University Hospital, Minami-ku. 10. Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo. 11. Department of Respiratory Medicine, National Hospital Organization, Hokkaido Medical Center, Nishi-ku, Sapporo-shi. 12. Department of Respiratory Medicine, National Hospital Organization, Okinawa National Hospital, Ginowan-shi. 13. Department of Respiratory Medicine, Suzuka General Hospital, Yasuzuka-cho, Mie, Japan. 14. Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor Scott and White Health, Dallas, Texas. 15. Division of Pulmonary and Critical Care Medicine, New York Presbyterian-Weill Cornell Medical Center.
Abstract
BACKGROUND: Empiric therapy of pneumonia is currently based on the site of acquisition (community or hospital), but could be chosen, based on risk factors for multidrug-resistant (MDR) pathogens, independent of site of acquisition. METHODS: We prospectively applied a therapeutic algorithm based on MDR risks, in a multicenter cohort study of 1089 patients with 656 community-acquired pneumonia (CAP), 238 healthcare-associated pneumonia (HCAP), 140 hospital-acquired pneumonia (HAP), or 55 ventilator-associated pneumonia (VAP). RESULTS: Approximately 83% of patients were treated according to the algorithm, with 4.3% receiving inappropriate therapy. The frequency of MDR pathogens varied, respectively, with VAP (50.9%), HAP (27.9%), HCAP (10.9%), and CAP (5.2%). Those with ≥2 MDR risks had MDR pathogens more often than those with 0-1 MDR risk (25.8% vs 5.3%, P < .001). The 30-day mortality rates were as follows: VAP (18.2%), HAP (13.6%), HCAP (6.7%), and CAP (4.7%), and were lower in patients with 0-1 MDR risks than in those with ≥2 MDR risks (4.5% vs 12.5%, P < .001). In multivariate logistic regression analysis, 5 risk factors (advanced age, hematocrit <30%, malnutrition, dehydration, and chronic liver disease), as well as hypotension and inappropriate therapy were significantly correlated with 30-day mortality, whereas the classification of pneumonia type (VAP, HAP, HCAP, CAP) was not. CONCLUSIONS: Individual MDR risk factors can be used in a unified algorithm to guide and simplify empiric therapy for all pneumonia patients, and were more important than the classification of site of pneumonia acquisition in determining 30-day mortality. CLINICAL TRIALS REGISTRATION: JMA-IIA00146.
BACKGROUND: Empiric therapy of pneumonia is currently based on the site of acquisition (community or hospital), but could be chosen, based on risk factors for multidrug-resistant (MDR) pathogens, independent of site of acquisition. METHODS: We prospectively applied a therapeutic algorithm based on MDR risks, in a multicenter cohort study of 1089 patients with 656 community-acquired pneumonia (CAP), 238 healthcare-associated pneumonia (HCAP), 140 hospital-acquired pneumonia (HAP), or 55 ventilator-associated pneumonia (VAP). RESULTS: Approximately 83% of patients were treated according to the algorithm, with 4.3% receiving inappropriate therapy. The frequency of MDR pathogens varied, respectively, with VAP (50.9%), HAP (27.9%), HCAP (10.9%), and CAP (5.2%). Those with ≥2 MDR risks had MDR pathogens more often than those with 0-1 MDR risk (25.8% vs 5.3%, P < .001). The 30-day mortality rates were as follows: VAP (18.2%), HAP (13.6%), HCAP (6.7%), and CAP (4.7%), and were lower in patients with 0-1 MDR risks than in those with ≥2 MDR risks (4.5% vs 12.5%, P < .001). In multivariate logistic regression analysis, 5 risk factors (advanced age, hematocrit <30%, malnutrition, dehydration, and chronic liver disease), as well as hypotension and inappropriate therapy were significantly correlated with 30-day mortality, whereas the classification of pneumonia type (VAP, HAP, HCAP, CAP) was not. CONCLUSIONS: Individual MDR risk factors can be used in a unified algorithm to guide and simplify empiric therapy for all pneumoniapatients, and were more important than the classification of site of pneumonia acquisition in determining 30-day mortality. CLINICAL TRIALS REGISTRATION: JMA-IIA00146.
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