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A2619 - Antibiogram Directed Treatment for Hospital-Acquired Pneumonia Across All Veterans Affairs Medical Centers
Author Block: A. Bostwick1, M. Jones2, M. Goetz3, M. Samore2, R. Paine4, B. E. Jones1; 1Pulmonary and Critical Care, University of Utah, Salt Lake City, UT, United States, 2Infectious Disease, University of Utah, Salt Lake City, UT, United States, 3Infectious Disease, University of California, Los Angeles, Los Angeles, UT, United States, 4Univ of Utah, Salt Lake City, UT, United States.
Background: In 2016, the American Thoracic Society (ATS) and Infectious Disease Society of America (IDSA) published guidelines for the treatment of hospital-acquired and ventilator-associated pneumonia (HAP, VAP), recommending antimicrobial selection based upon patient-specific risk factors and hospital generated antibiograms. For HAP, coverage for methicillin-resistant Staphylococcus aureus (MRSA) is recommended if prevalence of resistance is >20% or unknown. For VAP, coverage for MRSA is recommended if prevalence of resistance is >10% or unknown; and two anti-pseudomonal agents are recommended if the prevalence of gram negative rod (GNR) resistance is >10% or unknown. The implications of these guidelines are unknown, as is the prevalence of resistance.
Objective: To 1) describe existing national availability of pneumonia and location specific antibiograms 2) describe how often MRSA coverage and 2 anti-pseudomonal agents would be recommended based on resistance rates and antibiogram availability.
Methods: We conducted a retrospective analysis evaluating cultures from all Veterans Affairs Medical Centers (VAMCs) in 2014 to determine the prevalence of MRSA and resistant GNR. For each VAMC, we calculated the prevalence of resistance if ≥ 30 cultures were available during 2014. We calculated the percent of hospitals able to generate pneumonia-specific antibiograms and location-specific antibiograms (acute care service vs ICU). We then measured the percent of hospitals where patients would be recommended to receive multidrug-resistant (MDR) treatment based off their local prevalence data.
Results: Of 113 VAMCs, we found 84/113 (74%) could generate MRSA-specific antibiograms from all cultures. However, only 16/113 (14%) could generate HAP-specific antibiograms for MRSA. For VAP, 2/113 (2%) could generate antibiograms for MRSA and 14/113 (12%) for GNR resistance. For the ICUs, 17/113 (15%) could generate MRSA antibiograms and 68/113 (60%) could generate GNR antibiograms. Regardless of setting, all VAMCs where MRSA prevalence data were available had >20% resistance, indicating that MRSA coverage would be recommended for all patients developing HAP or VAP across the VA system. Additionally, if VAP developed in 86 of 113 (76%) ICU’s, 2 anti-pseudomonal agents would be recommended.
Conclusion: In a large national study, we found that an exceedingly high proportion of patients met criteria for MDR coverage according to the guidelines antibiogram-based treatment thresholds, regardless of patient-specific risk factors for resistance. We also found the ability to develop pneumonia or ICU-specific antibiograms from 1 year of data was limited. Guidelines that focus on hospital prevalence data and different treatment thresholds may simplify clinical decision-making and decrease unnecessary use of broad-spectrum antibiotics.