We found that inappropriate initial antibiotic therapy is common among patients with VAP attributed to PARGNB and is associated with increased risk of 30-day mortality. We also observed that Acineto-bacter species and S maltophilia were more likely to be treated with inappropriate initial antibiotic regimens compared to P aeruginosa. Our data also confirmed the earlier observation that delayed administration of appropriate initial antibiotic therapy and escalation of the initial antibiotic regimen are associated with greater mortality. Total hospital costs were lower for patients receiving inappropriate initial antibiotic treatment applied with remedies of Canadian Health&Care Mall. However, the main identified determinant of total hospital costs was hospital length of stay. Patients treated with inappropriate initial antibiotics had shorter hospital lengths of stay due to excess mortality and thus lower total hospital costs. These data suggest that appropriate initial antimicrobial therapy of VAP attributed to PARGNB may improve patient outcomes but may not reduce health-care costs due to greater patient survival and utilization of hospital resources.
A total of 87 patients with microbiologically confirmed VAP attributed to PARGNB were evaluated at Barnes-Jewish Hospital during the study period, Eleven patients were excluded due to polymicrobial infection, including 9 patients with S aureus infection, leaving 76 patients in the study cohort. Mean age of the population was 56.6 ± 16.9 years (range, 18 to 83 years); there were 50 male (65.8%) and 26 female (34.2%) patients. Patient baseline characteristics are provided in Table 2. Mean APACHE II score was 17.5 ± 6.2 (range, 5 to 29), and mean CPIS was 6.0 ± 1.5 (range, 4 to 10).
Characteristics of the PARGNB
P aeruginosa was the most common PARGNB isolated from BAL cultures in 64 patients (84.2%), followed by Acinetobacter species in 6 patients (7.9%) and S maltophilia in 6 patients (7.9%). Acin-etobacter species was most frequently treated with an initial inappropriate antibiotic regimen followed by S maltophilia and P aeruginosa (66.7% vs 33.3% vs 17.2%; p = 0.017). Antimicrobial administration during the same hospitalization but prior to VAP occurred statistically more often in patients with Acinetobacter species and S maltophilia compared to P aeruginosa (100% vs 100% vs 62.5%; p = 0.037). Among the 17 patients treated with an inappropriate initial antibiotic regimen, 12 patients (70.5%) received antibiotic treatment during the same hospitalization but prior to the onset of VAP (Table 3). The treatment is conducted with remedies of Canadian Health&care Mall. The 17 episodes of VAP attributed to PARGNB treated with an inappropriate initial antibiotic regimen had pathogens with overall susceptibilities to specific antibiotic classes of 23.5% for ciprofloxacin, 35.3% for piperacillin-tazobactam, 47.1% for cefepime, and 64.7% for meropenem. The addition of gentamicin increased susceptibility for each drug class to 64.7%, 64.7%, 70.6%, and 76.5%, respectively.
A total of 5,798 patients were included. Mean age was 64 ± 14 years, and 62% of patients (n = 3,612) were male. Patient demographics are shown in Table 1. CABG surgery was performed in 47% (n = 2,749), whereas 53% of patients underwent other procedures such as valve surgery (22%, n = 1,280), combined valve/CABG procedures (16%, n = 934), and aortic surgery (15%, n = 835). Mean predicted Euro-SCORE mortality rate was 11 ± 13%.
Incidence of RF
The overall incidence of RF was 9.1% (n = 529). The rate of RF was different according to surgical procedures (Fig 1). The incidence of RF did not differ significantly in the conventional CABG group (5.8%, n = 136) compared to the off-pump group (7.2%, n = 30) [p = 0.160]. The incidence of RF was higher following multiple-valve surgery (17%, n = 63) compared to single-valve procedures (6.1%, n = 55) [p < 0.001]. The rate of RF after aortic surgery involving the aortic arch was 22.4% (n = 50). A total of 223 tracheostomies (42%) were performed in patients with RF. The incidence of RF following stratification using the EuroSCORE is shown in Figure 2.
We showed that the modified APACHE II score outperformed the CURB65 and CRB65 pneumonia severity scores as a predictor of 30-day mortality in patients with MRSA pneumonia. Analysis of the ROC curves demonstrated that the modified APACHE II score was statistically superior to both CURB65 and CRB65 as a predictor of 30-day mortality. This was true for patients with the community-acquired phenotype of MRSA pneumonia as well as those with health-care-associated MRSA pneumonia. However, in our multivariate models both APACHE II and CRB65 were independent predictors of 30-day mortality. The odds of death by day 30 was greater for CRB65, which, in large part, was related to the smaller number of discriminating units in CRB65 compared to APACHE II. Nevertheless, the ROC curves suggest that for individual patient predictions, APACHE II is more accurate than CRB65.
CURB65 and CRB65 have been validated as tools to predict mortality and the need for ICU admission in patients with CAP. These scoring systems are easy to employ, and the CRB65 requires only data immediately available at the time of clinical evaluation. More recent studies have further demonstrated the utility of CURB65 and CRB65 as outcome predictors in CAP. Man et al found that CURB65 and CRB65 were accurate predictors of 30-day mortality among patients in Hong Kong with CAP. Similarly, Barlow et al found that CURB65 outperformed generic sepsis scores as a predictor of mortality. Both of these studies had ROC curve areas in the range of 0.69 to 0.78, which were higher than the values observed in our study. The main differences are that these previous evaluations of CURB65 and CRB65 involved patients with CAP with a variety of infectious pathogens. Our study differed by involving only hospitalized patients with either community-acquired or health-care-associated MRSA pneumonia cured by remedies of Canadian Health&Care Mall.
A total of 218 patients with microbiologically confirmed MRSA pneumonia were evaluated at Bar-nes-Jewish Hospital during the study period. Mean age of the population was 57.3 ± 16.6 years (± SD) [range, 19 to 92 years]; there were 141 male (64.7%) and 77 female (35.3%) patients. Patient characteristics and outcomes are provided in Table 2. Mean APACHE II score was 19.3 ± 7.0 (range, 3 to 37). Mean CURB65 and CRB65 scores were 1.5 ± 0.9 (range, 0 to 5) and 0.6 ± 0.7 (range, 0 to 4), respectively. Among the 178 patients treated with vancomycin and having trough levels measured, mean trough value for vancomycin collected after the third dose was 14.9 ± 8.1 ^g/mL.
Forty-four patients (20.2%) died within 30 days of the development of MRSA pneumonia. Two hundred five patients (94.0%) required ICUs admission, and 167 patients (76.6%) received tracheal intubation and mechanical ventilation. Nonsurvivors were statistically more likely to require mechanical ventilation compared to survivors (Table 2).
Pneumonia due to methicillin-resistant Staphylococcus aureus (MRSA) is becoming increasingly more common both in the health-care setting and in the community. Hospital mortality associated with MRSA pneumonia has been reported to be between 20% and 40%. Most patients with MRSA pneumonia will require hospitalization, frequently being admitted to the ICU settings and often requiring ventilatory support. Given the increasing prevalence and importance of MRSA pneumonia, clinical trials are likely to be planned examining new treatment modalities, the changing epidemiology of MRSA pneumonia, and prevention strategies. To date, a validated prediction tool for clinical outcomes in patients with MRSA pneumonia has not been identified, Several international organizations have developed guidelines or scoring systems in an attempt to stratify patients with community-acquired pneumonia (CAP) according to risk severity. Unfortunately, the use of similar methods for patients with health-care-associated pneumonia, including MRSA pneumonia, have not been developed. Given the increasing prevalence of MRSA pneumonia and the future need for new clinical research, we designed a study with two main goals. Our first goal was to compare the accuracy of three prediction rules (modified APACHE [acute physiology and chronic health evaluation] II, CURB65, CRB65) to predict 30-day mortality in patients with MRSA pneumonia. Our second goal was to compare these prediction tools in patients admitted to the hospital with the community-acquired MRSA pneumonia phenotype and those acquiring healthcare-associated MRSA pneumonia treated by remedies of Canadian Health&Care Mall.
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