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Impact of Antibiotic Guideline Compliance on Duration of Mechanical Ventilation in Critically Ill Patients With Community-Acquired Pneumonia^*

Andrew F. Shorr, MD, MPH, FCCP; Maria Bodi, MD; Alejandro Rodriguez, MD; Jorge Sole-Violan, MD, PhD; Jose Garnacho-Montero, PhD; Jordi Rello, MD, PhD; for the CAPUCI Study Investigators

^* From the Pulmonary and Critical Care Section (Dr. Shorr), Department of Medicine, Washington Hospital Center, Washington, DC; the Critical Care Department (Drs. Bodi, Rodriquez, and Rello), Joan XXIII University Hospital, Tarragona, Spain; the Critical Care Department (Dr. Sole-Violan), Hospital Negrin, Las Palmas, Spain; and Critical Care Department (Dr. Garnacho-Montero), Hospital Virgen del Rocio, Seville, Spain. A list of CAPUCI Study Investigators is given in the ^Appendix.

Correspondence to: Andrew F. Shorr, MD, MPH, FCCP, Pulmonary and Critical Care Medicine, Room 2A-38D, Washington Hospital Center, Washington, DC 20010; e-mail: afshorr{at}dnamail.com

Abstract

Objective: Multiple guidelines exist to aid clinicians in choosing antibiotics to treat patients with severe community-acquired pneumonia (SCAP). Our goal was to assess the impact of following these guidelines, such as those from the Infectious Disease Society of America (IDSA), on the duration of mechanical ventilation (MV).

Design: Analysis of a prospective registry.

Setting: Multiple ICUs in Spain.

Patients: ICU patients with SCAP requiring 24 h of endotracheal intubation and surviving their ICU course.

Interventions: None.

Measurements and main results: Demographics, comorbid diseases, severity of illness, and process of care variables were recorded. The duration of MV in patients receiving an antibiotic regimen consistent with IDSA guidelines was compared to patients with prescriptions not in accordance with IDSA recommendations. In the cohort (n = 199), Streptococcus pneumoniae was the most frequent pathogen, and unadjusted analysis showed that the duration of MV was longer in persons receiving IDSA-noncompliant regimens (11 days vs 10 days). In a multivariate hazard model, two variables were independently associated with greater durations of MV: development of acute renal failure (hazard ratio, 1.47; 95% confidence interval [CI], 1.02 to 2.12), and prescription of an IDSA-noncompliant regimen (hazard ratio, 1.40; 95% CI, 1.02 to 1.93). Adjusted analysis indicated that patients receiving treatment that was not compliant with IDSA guidelines received MV an added 3 days.

Conclusion: Failure to follow antibiotic recommendations for the treatment of SCAP may increase the need for continuing MV. Conversely, guideline compliance could represent a surrogate marker that captures other aspects of clinical care, rather than be the direct factor leading to better outcomes. Nonetheless, given the costs associated with MV, enhanced guideline compliance may represent a means for improving outcomes and enhancing resource utilization.

Key Words: antibiotics • community-acquired pneumonia • guidelines • mechanical ventilation • outcomes