Hostname: page-component-8448b6f56d-xtgtn Total loading time: 0 Render date: 2024-04-18T12:26:06.142Z Has data issue: false hasContentIssue false
  • English
  • Français

Variation in Empiric Coverage Versus Detection of Methicillin-Resistant Staphylococcus aureus and Pseudomonas aeruginosa in Hospitalizations for Community-Onset Pneumonia Across 128 US Veterans Affairs Medical Centers

Published online by Cambridge University Press:  21 June 2017

Barbara E. Jones ,
Kevin Antoine Brown ,
Makoto M. Jones ,
Benedikt D. Huttner ,
Tom Greene ,
Brian C. Sauer ,
Karl Madaras-Kelly ,
Michael A. Rubin ,
Matthew Bidwell Goetz  and
Matthew H. Samore
Barbara E. Jones*
Affiliation:
VA Salt Lake City IDEAS Center, VA Salt Lake City Health Care System, Salt Lake City, Utah Division of Pulmonary & Critical Care Medicine, University of Utah, Salt Lake City, Utah
Kevin Antoine Brown
Affiliation:
VA Salt Lake City IDEAS Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
Makoto M. Jones
Affiliation:
VA Salt Lake City IDEAS Center, VA Salt Lake City Health Care System, Salt Lake City, Utah Division of Epidemiology, University of Utah, Salt Lake City, Utah
Benedikt D. Huttner
Affiliation:
VA Salt Lake City IDEAS Center, VA Salt Lake City Health Care System, Salt Lake City, Utah Division of Infectious Diseases and Infection Control Program, Geneva University Hospitals and Faculty of Medicine, University of Geneva
Tom Greene
Affiliation:
Division of Epidemiology, University of Utah, Salt Lake City, Utah
Brian C. Sauer
Affiliation:
VA Salt Lake City IDEAS Center, VA Salt Lake City Health Care System, Salt Lake City, Utah Division of Epidemiology, University of Utah, Salt Lake City, Utah
Karl Madaras-Kelly
Affiliation:
Boise Veterans Affairs Medical Center, Meridian, Idaho College of Pharmacy, Idaho State University, Meridian, Idaho
Michael A. Rubin
Affiliation:
VA Salt Lake City IDEAS Center, VA Salt Lake City Health Care System, Salt Lake City, Utah Division of Epidemiology, University of Utah, Salt Lake City, Utah
Matthew Bidwell Goetz
Affiliation:
Division of Infectious Disease, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California David Geffen School of Medicine at University of California–Los Angeles, Los Angeles, California
Matthew H. Samore
Affiliation:
VA Salt Lake City IDEAS Center, VA Salt Lake City Health Care System, Salt Lake City, Utah Division of Epidemiology, University of Utah, Salt Lake City, Utah
*
Address correspondence to Barbara E. Jones, MD, MSc, Division of Pulmonary and Critical Care Medicine, Salt Lake City Veterans Affairs Health System, 30N 1900 E 701 Wintrobe, Salt Lake City, UT 84132 (Barbara.jones@hsc.utah.edu).
Get access Rights & Permissions [Opens in a new window]

Abstract

OBJECTIVE

To examine variation in antibiotic coverage and detection of resistant pathogens in community-onset pneumonia.

DESIGN

Cross-sectional study.

SETTING

A total of 128 hospitals in the Veterans Affairs health system.

PARTICIPANTS

Hospitalizations with a principal diagnosis of pneumonia from 2009 through 2010.

METHODS

We examined proportions of hospitalizations with empiric antibiotic coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (PAER) and with initial detection in blood or respiratory cultures. We compared lowest- versus highest-decile hospitals, and we estimated adjusted probabilities (AP) for patient- and hospital-level factors predicting coverage and detection using hierarchical regression modeling.

RESULTS

Among 38,473 hospitalizations, empiric coverage varied widely across hospitals (MRSA lowest vs highest, 8.2% vs 42.0%; PAER lowest vs highest, 13.9% vs 44.4%). Detection rates also varied (MRSA lowest vs highest, 0.5% vs 3.6%; PAER lowest vs highest, 0.6% vs 3.7%). Whereas coverage was greatest among patients with recent hospitalizations (AP for anti-MRSA, 54%; AP for anti-PAER, 59%) and long-term care (AP for anti-MRSA, 60%; AP for anti-PAER, 66%), detection was greatest in patients with a previous history of a positive culture (AP for MRSA, 7.9%; AP for PAER, 11.9%) and in hospitals with a high prevalence of the organism in pneumonia (AP for MRSA, 3.9%; AP for PAER, 3.2%). Low hospital complexity and rural setting were strong negative predictors of coverage but not of detection.

CONCLUSIONS

Hospitals demonstrated widespread variation in both coverage and detection of MRSA and PAER, but probability of coverage correlated poorly with probability of detection. Factors associated with empiric coverage (eg, healthcare exposure) were different from those associated with detection (eg, microbiology history). Providing microbiology data during empiric antibiotic decision making could better align coverage to risk for resistant pathogens and could promote more judicious use of broad-spectrum antibiotics.

Infect Control Hosp Epidemiol 2017;38:937–944

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 38 , Issue 8 , August 2017 , pp. 937 - 944
Copyright
© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1. National Center for Health Statistics. Fastats: Pneumonia. Centers for Disease Control and Prevention website. http://www.cdc.gov/nchs/fastats/pneumonia.htm. Updated 2017. Accessed April 21, 2017.Google Scholar
2. US, Burden of Disease Collaborators. The state of US health, 1990–2010: burden of diseases, injuries, and risk factors. JAMA 2013;310:591–608.Google Scholar
3. Mandell, LA, Wunderink, RG, Anzueto, A, et al. Infectious Diseases Society of America; American Thoracic Society, Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2):S27–S72.CrossRefGoogle Scholar
4. American Thoracic Society. Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388–416.CrossRefGoogle Scholar
5. Facts about ORYX for hospitals (National Hospital Quality Measures). The Joint Commission website. http://www.jointcommission.org/assets/1/6/ORYX_for_Hospitals.pdf. Updated 2017. Accessed April 21, 2017.Google Scholar
6. Jones, BE, Jones, MM, Huttner, B, et al. Trends in antibiotic use and nosocomial pathogens in hospitalized veterans with pneumonia at 128 medical centers, 2006–2010. Clin Infect Dis 2015;61:1403–1410.Google Scholar
7. Self, WH, Wunderink, RG, Williams, DJ, et al. Staphylococcus aureus community-acquired pneumonia: prevalence, clinical characteristics, and outcomes. Clin Infect Dis 2016;63:300–309.Google Scholar
8. Wunderink, RG. Community-acquired pneumonia versus healthcare-associated pneumonia. The returning pendulum. Am J Respir Crit Care Med 2013;188:896–898.Google Scholar
9. Flanders, SA, Halm, EA. Guidelines for community-acquired pneumonia: are they reflected in practice? Treat Respir Med 2004;3:67–77.Google Scholar
10. Aliberti, S, Di Pasquale, M, Zanaboni, AM, et al. Stratifying risk factors for multidrug-resistant pathogens in hospitalized patients coming from the community with pneumonia. Clin Infect Dis 2012;54:470e8.Google Scholar
11. Schreiber, MP, Chan, CM, Shorr, AF. Resistant pathogens in nonnosocomial pneumonia and respiratory failure: is it time to refine the definition of health-care-associated pneumonia? Chest 2010;137:1283–1288.Google Scholar
12. Lindenauer, PK, Lagu, T, Shieh, MS, et al. Association of diagnostic coding with trends in hospitalizations and mortality of patients with pneumonia, 2003–2009. JAMA 2012;307:1405–1413.Google Scholar
13. Rhunke, GW, Coca-Perraillon, M, Kitch, BT, Cutler, DM. Marked reduction in 30-day mortality among elderly patients with community-acquired pneumonia. Am J Med 2011;124:171–178.Google Scholar
14. US Department of Veterans Affairs. VA Informatics and Computing Infrastructure (VINCI). http://hsrd.research.va.gov/for_researchers/vinci. Accessed February 19, 2016.Google Scholar
15. 2012 VHA facility quality and safety report. Department of Veterans Affairs, Veterans Health Administration website. https://www.va.gov/HEALTH/docs/VHA_Quality_and_Safety_Report_2013.pdf. Published 2013. Accessed May 11, 2017.Google Scholar
16. Christiansen, CL, Morris, CN. Improving the statistical approach to health care provider profiling. Ann Intern Med 1997;127:764–768.Google Scholar
17. SNOMed International website. http://www.snomed.org. Accessed April 21, 2017.Google Scholar
18. Schneider, R, Bagby, J, Carlson, R. Bar-code medication administration: a systems perspective. Am J Health Syst Pharm 2008;65:2216, 8–9.Google Scholar
19. Austin, PC. Absolute risk reductions, relative risks, relative risk reductions, and numbers needed to treat can be obtained from a logistic regression model. J Clin Epidemiol 2010;63:2–6.CrossRefGoogle ScholarPubMed
20. Fox, J. Bootstrapping regression models. Appendix to An R and S-PLUS Companion to Applied Regression website. https://socserv.socsci.mcmaster.ca/jfox/Books/Companion-1E/appendix-bootstrapping.pdf. Published January 2002 and corrected January 2008). Accessed April 21, 2017.Google Scholar
21. Sibila, O, Rodrigo-Troyano, A, Shindo, Y, Aliberti, S, Restrepo, MI. Multidrug-resistant pathogens in patients with pneumonia coming from the community. Curr Opin Pulm Med 2016;22:219–226.CrossRefGoogle ScholarPubMed
22. Chalmers, JD, Rother, C, Salih, W, Ewig, S. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis. Clin Infect Dis 2014;58:330–339; Erratum: Clin Infect Dis 2015;60:1143.Google Scholar
23. Madaras-Kelly, KJ, Remington, RE, Fan, VS, Sloan, KL. Predicting antibiotic resistance to community-acquired pneumonia antibiotics in culture-positive patients with healthcare-associated pneumonia. J Hosp Med 2012;7:195–202.CrossRefGoogle ScholarPubMed
24. Metersky, ML, Frei, CR, Mortensen, EM. Predictors of Pseudomonas and methicillin-resistant Staphylococcus aureus in hospitalized patients with healthcare-associated pneumonia. Respirology 2016;21:157–163.Google Scholar
25. Jones, M, Ying, J, Huttner, B, et al. Relationships between the importation, transmission, and nosocomial infections of methicillin-resistant Staphylococcus aureus: an observational study of 112 Veterans Affairs Medical Centers. Clin Infect Dis 2014;58:32–39.Google Scholar
26. Pollack, M. Pseudomonas aeruginosa . In: Mandell GL, Bennett JE, Dolin R, eds Principles and Practice of Infectious Diseases. 5th ed. New York, NY: Churchill Livingstone; 2000.Google Scholar
27. Thomas, JC, Weber, DJ. Epidemiologic Methods for the Study of Infectious Diseases. Oxford: Oxford University Press; 2001.Google Scholar
28. Shorr, AF, Zilberberg, MD, Micek, ST, Kollef, MH. Prediction of infection due to antibiotic-resistant bacteria by select risk factors for health care-associated pneumonia. Archives Intern Med 2008;168:2205–2210.Google Scholar
29. Shindo, Y, Ito, R, Kobayashi, D, Ando, M, et al. Risk factors for drug-resistant pathogens in community-acquired and healthcare-associated pneumonia. Am J Respir Crit Care Med 2013;188:985–995.Google Scholar
30. Webb, BJ, Dascomb, K, Stenehjem, E, et al. Derivation and multicenter validation of the drug resistance in pneumonia clinical prediction score. Antimicrob Agents Chemother 2016;60:2652–2663.Google Scholar
31. Kalil, AC, Metersky, ML, Klompas, M, et al. Executive summary: management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016;63:575–582.Google Scholar
32. Waterer, GW. Healthcare-associated pneumonia: can we salvage anything from the wreckage? Respirology 2016;21:8–9.Google Scholar
33. Chalmers, JD, Reyes, LF, Aliberti, S, Restrepo, MI. Empirical coverage of MRSA in community-acquired pneumonia: those who do not remember the past are doomed to repeat it. Clin Infect Dis 2016;63:1145–1146.Google Scholar
34. Hindler, JF, Stelling, J. Analysis and presentation of cumulative antibiograms: a new consensus guideline from the Clinical and Laboratory Standards Institute. Clin Infect Dis 2007;44:867–873.Google Scholar
35. Swami, SK, Banerjee, R. Comparison of hospital-wide and age and location-stratified antibiograms of S. aureus, E. coli, and S. pneumoniae: age-and location-stratified antibiograms. SpringerPlus 2013;2:63.Google Scholar
36. Bosso, JA, Sieg, A, Mauldin, PD. Comparison of hospitalwide and custom antibiograms for clinical isolates of Pseudomonas aeruginosa . Hosp Pharmacy 2013;48:295–301.Google Scholar
37. Jones, M, Huttner, B, Leecaster, M, et al. Does universal active MRSA surveillance influence anti-MRSA antibiotic use? A retrospective analysis of the treatment of patients admitted with suspicion of infection at Veterans Affairs Medical Centers between 2005 and 2010. J Antimicrob Chemother 2014;69:3401–3408.CrossRefGoogle ScholarPubMed
Supplementary material: File

Jones supplementary material

Appendix

Download Jones supplementary material(File)
File 131.6 KB