Questionable benefits of guidelines for pneumonia management in intensive care

January 01, 0001

Questionable benefits of guidelines for pneumonia management in intensive care

The American Thoracic Society and Infectious Diseases Society of America provide guidelines for management of hospital-acquired, ventilator-associated, and health-care- associated pneumonias, consisting of empirical antibiotic regimens for patients at risk for multidrug-resistant pathogens. The researchers from the USA aimed to improve compliance with these guidelines and assess outcomes. They implemented a performance-improvement initiative in four academic medical centres in the USA with protocol-based education and prospective observation of outcomes. Patients were assessed for severity of illness and followed up until death, hospital discharge, or day 28. 303 patients at risk for multidrug-resistant pneumonia were treated empirically, and prescribed treatment was guideline compliant in 129 patients and non-compliant in 174 patients.

34% patients died before 28 days in the compliance group and 20% died in the non-compliance group. Five patients in the compliance group and seven in the non-compliance group were lost to follow-up after day 14. Kaplan-Meier estimated survival to 28 days was 65% in the compliance group and 79% in the non-compliance group (significant). This difference persisted after adjustment for severity of illness. Median length of stay and duration of mechanical ventilation did not differ between groups. Compliance failures included non-use of dual treatment for Gram-negative pathogens in 154 patients and absence of methicillin-resistant Staphylococcus aureus coverage in 24 patients. For patients in whom pathogens were subsequently identified, empirical treatment was active in 81% of 97 of patients receiving compliant therapy compared with 85% of 128 of patients receiving non-compliant therapy.

The researchers concluded: "Because adherence with empirical treatment was associated with increased mortality, we recommend a randomised trial be done before further implementation of these guidelines."

A reminder that EBM is ongoing and that guidelines are just that.

For the full abstract, click here.

The Lancet Infectious Diseases published online 20 January 2011 © 2011 Elsevier Limited
Implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care: an observational, multicentre cohort study. Daniel H Kett, Ennie Cano, Andrew A Quartin et al for the Improving Medicine through Pathway Assessment of Critical Therapy of Hospital-Acquired Pneumonia (IMPACT-HAP) Investigators. Correspondence to Daniel Kett: [email protected]

Category: R. Respiratory, HSR. Health Services Research Keywords: guidelines, implementation management, pneumonia, intensive care, drug resistant, observational, multicentre cohort study, journal watch.
Synopsis edited by Dr Stephen Wilkinson, Melbourne, Australia. Posted on Global Family Doctor 11 February 2011

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