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A4462 - Practice Patterns for Hospital-Acquired Pneumonia at All Veterans Affairs Medical Centers
Author Block: A. Bostwick1, B. E. Jones1, M. Goetz2, M. Samore3, R. Paine4, M. Jones3; 1Pulmonary and Critical Care, University of Utah, Salt Lake City, UT, United States, 2Infectious Disease, University of California, Los Angeles, Los Angeles, CA, United States, 3Infectious Disease, University of Utah, Salt Lake City, 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 new guidelines for the treatment of hospital-acquired pneumonia (HAP) recommending non-invasive culturing, antimicrobial selection based upon pre-specified risk factors and a hospital generated antibiogram, and timely antibiotic de-escalation based upon culture results. Objective: To 1) describe existing national practice patterns for HAP prior to the guidelines, including the frequency of initial treatment for multi-drug resistant organism, culture methods, and de-escalation of antibiotics; and 2) estimate the change in practices with guideline implementation. Methods: We conducted a retrospective analysis of all non-infectious hospitalizations at Veterans Affairs Medical Centers between October 1, 2012 and September 30, 2015 with a secondary diagnosis of pneumonia and who received antibiotics and cultures only after 48 hours of their admission. We excluded hospitalizations with a principal diagnosis for pneumonia, respiratory failure, or sepsis, or in which antibiotics were administered within the first 48 hours of admission. We calculated the incidence rate of HAP per 10,000 hospital days and the percent of hospitalizations where empiric antibiotics were administered for multi drug resistant organisms (MDRO). Resistant gram negative rods (GNR) were defined as any GNR resistant to piperacillin-tazobactam. Our secondary outcome measured the percent of patients with antibiotic de-escalation within 48 hours of initiation and the percent of patients that had both blood and respiratory cultures obtained. Results: Between 2012 and 2015, we identified 3,562 cases of HAP among all non-infectious hospitalizations. Chart review of 100 cases found a positive predictive value of 92%. The incidence rate of HAP was 3.7 per 10,000 hospital days. Eighty-eight percent of HAP patients had both respiratory and blood cultures drawn. Only 4% of cultured patients had MRSA or resistant GNR. Fifty-eight percent of HAP patients were treated for MRSA and 77% were treated for resistant GNR. Twenty-nine percent received more than one antibiotic against pseudomonas. Fifty-three percent who received empiric MRSA treatment were de-escalated in 48hrs if there was no MRSA growth on culture but only 15% de-escalated from anti-pseudomonal treatment. Conclusion: In a large national study of patients with HAP, we found the number of patients treated with antibiotics against MDR pathogens far exceeded the number of cultures found to display antibiotic resistance. Additionally, timely de-escalation was only completed half the time for MRSA and rarely done for Pseudomonas. Guideline implementation focusing on antibiotic de-escalation and culture-directed therapy provide great opportunities for stewardship.