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Implementing national guidelines in intensive care patients with ventilator-associated, hospital-acquired, and healthcare-associated pneumonia: the IMPACT-HAP project
Critical Care volume 12, Article number: P434 (2008)
In an effort to decrease the gap between the current management of pneumonia in the ICU and the recommendations by the 2005 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA), we developed, implemented and evaluated an ICU hospital-acquired pneumonia performance improvement (PI) project by adapting these guidelines in four academic hospitals.
PI indicators were developed and assessed. PI1 evaluated the initial microbiological work-up (lower airway and blood cultures within 48 hours). PI2 assessed empiric antibiotics in patients with risk factors for multidrug-resistant organisms. PI3 evaluated patients for short-course therapy (clinical pulmonary infection score ≤ 6 on day 0 and day 3 and no hemodynamic instability or severe sepsis). PI4 assessed whether patients were candidates for de-escalation and had their antibiotics adjusted on day 3. Data were collected prospectively and reviewed by the principal investigators prior to submission to the database.
Analysis was performed on the first 164 patients meeting the clinical criteria of pneumonia. Respiratory cultures were obtained in 94% and blood cultures were obtained in 88% of patients. One hundred and twenty-five patients received empiric therapy. The empiric therapy was compliant with the ATS/IDSA guidelines in only 31% of the patients, with failure to use a second agent to cover multidrug-resistant Gram-negative pathogens in 55% patients. Nineteen patients were candidates for short-course therapy, and this was implemented in one patient. De-escalation criteria was met in 106 patients and occurred in 75% of candidates.
Adherence to ATS/IDSA guidelines for diagnosis and management of hospital-acquired pneumonia was less than expected, but initial work-up with appropriate cultures was performed in the majority of patients. In patients at risk for multidrug-resistant organisms, empiric antibiotics were compliant with the guidelines only one-third of the time. De-escalation of antibiotic therapy, while not optimal, did occur in most candidates. In patients who were candidates for short-course therapy, this option was rarely chosen.
American Thoracic Society and Infectious Diseases Society of America: Am J Respir Crit Care Med. 2005, 71: 388-416.
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Kett, D., Ramirez, J., Peyrani, P. et al. Implementing national guidelines in intensive care patients with ventilator-associated, hospital-acquired, and healthcare-associated pneumonia: the IMPACT-HAP project. Crit Care 12, P434 (2008). https://doi.org/10.1186/cc6655
- Blood Culture
- Severe Sepsis
- Performance Improvement
- Hemodynamic Instability