Abhishek Deshpande1,2, Sandra S Richter3, Sarah Haessler4, Peter K Lindenauer5, Pei-Chun Yu6, Marya D Zilberberg7,8, Peter B Imrey6,9, Thomas Higgins10, Michael B Rothberg1. 1. Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio, USA. 2. Department of Infectious Diseases, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA. 3. Department of Clinical Pathology, Pathology Institute, Cleveland Clinic, Cleveland, Ohio, USA. 4. Division of Infectious Diseases, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA. 5. Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA. 6. Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA. 7. University of Massachusetts, Amherst, Massachusetts, USA. 8. EviMed Research Group, LLC, Goshen, Massachusetts, USA. 9. Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA. 10. Center for Case Management, Natick, Massachusetts, USA.
Abstract
BACKGROUND: For patients at risk for multidrug-resistant organisms, IDSA/ATS guidelines recommend empiric therapy against methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas. Following negative cultures, the guidelines recommend antimicrobial de-escalation. We assessed antibiotic de-escalation practices across hospitals and their associations with outcomes in hospitalized patients with pneumonia with negative cultures. METHODS: We included adults admitted with pneumonia in 2010-2015 to 164 US hospitals if they had negative blood and/or respiratory cultures and received both anti-MRSA and antipseudomonal agents other than quinolones. De-escalation was defined as stopping both empiric drugs on day 4 while continuing another antibiotic. Patients were propensity adjusted for de-escalation and compared on in-hospital 14-day mortality, late deterioration (ICU transfer), length-of-stay (LOS), and costs. We also compared adjusted outcomes across hospital de-escalation rate quartiles. RESULTS: Of 14 170 patients, 1924 (13%) had both initial empiric drugs stopped by hospital day 4. Hospital de-escalation rates ranged from 2-35% and hospital de-escalation rate quartile was not significantly associated with outcomes. At hospitals in the top quartile of de-escalation, even among patients at lowest risk for mortality, the de-escalation rates were <50%. In propensity-adjusted analysis, patients with de-escalation had lower odds of subsequent transfer to ICU (adjusted odds ratio, .38; 95% CI, .18-.79), LOS (adjusted ratio of means, .76; .75-.78), and costs (.74; .72-.76). CONCLUSIONS: A minority of eligible patients with pneumonia had antibiotics de-escalated by hospital day 4 following negative cultures and de-escalation rates varied widely between hospitals. To adhere to recent guidelines will require substantial changes in practice.
BACKGROUND: For patients at risk for multidrug-resistant organisms, IDSA/ATS guidelines recommend empiric therapy against methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas. Following negative cultures, the guidelines recommend antimicrobial de-escalation. We assessed antibiotic de-escalation practices across hospitals and their associations with outcomes in hospitalized patients with pneumonia with negative cultures. METHODS: We included adults admitted with pneumonia in 2010-2015 to 164 US hospitals if they had negative blood and/or respiratory cultures and received both anti-MRSA and antipseudomonal agents other than quinolones. De-escalation was defined as stopping both empiric drugs on day 4 while continuing another antibiotic. Patients were propensity adjusted for de-escalation and compared on in-hospital 14-day mortality, late deterioration (ICU transfer), length-of-stay (LOS), and costs. We also compared adjusted outcomes across hospital de-escalation rate quartiles. RESULTS: Of 14 170 patients, 1924 (13%) had both initial empiric drugs stopped by hospital day 4. Hospital de-escalation rates ranged from 2-35% and hospital de-escalation rate quartile was not significantly associated with outcomes. At hospitals in the top quartile of de-escalation, even among patients at lowest risk for mortality, the de-escalation rates were <50%. In propensity-adjusted analysis, patients with de-escalation had lower odds of subsequent transfer to ICU (adjusted odds ratio, .38; 95% CI, .18-.79), LOS (adjusted ratio of means, .76; .75-.78), and costs (.74; .72-.76). CONCLUSIONS: A minority of eligible patients with pneumonia had antibiotics de-escalated by hospital day 4 following negative cultures and de-escalation rates varied widely between hospitals. To adhere to recent guidelines will require substantial changes in practice.
Authors: Lionel A Mandell; Richard G Wunderink; Antonio Anzueto; John G Bartlett; G Douglas Campbell; Nathan C Dean; Scott F Dowell; Thomas M File; Daniel M Musher; Michael S Niederman; Antonio Torres; Cynthia G Whitney Journal: Clin Infect Dis Date: 2007-03-01 Impact factor: 9.079
Authors: Jefferson G Bohan; Richard Remington; Makoto Jones; Matthew Samore; Karl Madaras-Kelly Journal: Open Forum Infect Dis Date: 2016-12-10 Impact factor: 3.835
Authors: Kari A Mergenhagen; Kaitlyn E Starr; Bethany A Wattengel; Alan J Lesse; Zarchi Sumon; John A Sellick Journal: Clin Infect Dis Date: 2020-08-22 Impact factor: 9.079
Authors: Karl Madaras-Kelly; Makoto Jones; Richard Remington; Christina M Caplinger; Benedikt Huttner; Barbara Jones; Matthew Samore Journal: J Antimicrob Chemother Date: 2015-11-03 Impact factor: 5.790
Authors: Michael B Rothberg; Penelope S Pekow; Aruna Priya; Marya D Zilberberg; Raquel Belforti; Daniel Skiest; Tara Lagu; Thomas L Higgins; Peter K Lindenauer Journal: PLoS One Date: 2014-01-31 Impact factor: 3.240
Authors: Michael S Niederman; Rebecca M Baron; Lila Bouadma; Thierry Calandra; Nick Daneman; Jan DeWaele; Marin H Kollef; Jeffrey Lipman; Girish B Nair Journal: Crit Care Date: 2021-08-26 Impact factor: 9.097
Authors: Dan Ilges; David J Ritchie; Tamara Krekel; Elizabeth A Neuner; Nicholas Hampton; Marin H Kollef; Scott Micek Journal: Open Forum Infect Dis Date: 2021-11-17 Impact factor: 3.835