Study Reveals Surprising Findings That Certain Pneumonia Patients Don't Get Guideline Care

Physicians often do not follow treatment guidelines for health care-acquired pneumonia, resulting in nearly two-thirds of patients receiving antibiotics that conflict with established guidelines.

Doctors often don’t follow controversial guidelines on treating patients who acquire pneumonia associated with health care, according to findings from a large national database study presented at IDWeek 2012, an infectious disease conference held in San Diego.

The guidelines from the American Thoracic Society (ATS), which address how to manage cases of Health Care Associated Pneumonia (HCAP), have been controversial since they were published in 2005, said Sarah Haessler, MD, of the infectious disease division at Baystate Medical Center and assistant professor of medicine at Tufts University School of Medicine. The guidelines describe epidemiology, risk factors and diagnostic testing, and antibiotic management of HCAP, pneumonia in patients with close contact to the health care system.

“We found that there’s a large gap between what the guidelines are recommending for empiric antibiotics for patients who are being admitted with HCAP and what these patients are actually getting,” Haessler said.

The AHRQ-funded retrospective cohort study of 346 hospitals looked at data from 2007 to 2010 using Premier’s Perspective large national database of more than a million patients. The review included all adults with an ICD-9 code for pneumonia as their principal diagnosis, or as a secondary diagnosis paired with a principal diagnosis of either respiratory failure or sepsis.

The guidelines distinguish between two populations and this study focused on patients with late-onset HCAP, including the chronically ill, based on the presumption that colonization of MRSA was more likely among the target group, Haessler said.

“The ATS guidelines specify that we should be prescribing broad-spectrum empiric antibiotics and then narrowing our spectrum based on culture results,” she said.

Under the study parameters, ATS concordant care treatment guidelines were met if within 48 hours of being admitted, patients were given one antibiotic that targeted MRSA and two antibiotics that targeted pseudomonas. Partial concordance to guidelines was met if one antibiotic targeting MRSA and one targeting pseudomonas were given. Any other combinations were considered discordant.

To avoid including patients with community-acquired pneumonia (CAP), the study required that patients had at least one of the HCAP risk factors taken from ATS guidelines. The cases of pneumonia studied were defined as patients who had a radiographic study and were given antibiotics within 48 hours of admission, hospitalization in prior 90 days, hemodialysis, and admission from a skilled nursing facility or immune suppression.

Study results showed that nearly two-thirds of patients received antibiotics that conflicted with ATS guidelines. Specifically, of all 85,097 patients with HCAP, 14,809 (17.4%) received fully concordant, 17,140 (20.1%) received partially concordant, and 53,148 (62.5%) received discordant antibiotics. The median age of the study population was 73 years old and just over half of patients were women.

“Because we were rather surprised by that large percentage of patients who were getting discordant antibiotics, we asked ‘What antibiotics are they getting?’” Haessler said.

Researchers made a surprising discovery that 82% of patients treated outside of the HCAP guidelines were actually given antibiotics under (CAP) guidelines. “So they were being treated as community-acquired pneumonia,” Haessler said.

The study also found patients were more likely to get guideline concordant treatment if they were younger, were admitted to the intensive care unit, or had principal diagnosis of sepsis or respiratory failure.There were slight geographical differences in care with guidelines more likely to be followed in the northeast and south and at urban, teaching, and largehospitals.

Study limitations included a risk that some patients might not have had HCAP because the coding was not done by clinicians and the lack of outcome data not yet available to investigate whether patients faired differently because they received treatment outside of the guidelines.

“The implications of our study are that there appears to be a low level of physician buy-in for these relatively controversial guidelines and that hospital and regional variations in prescribing suggest that treatment strategies might be part of the local medical culture rather than guideline-driven,” Haessler said. “Finally, it appears that physicians are under recognizing risk factors for HCAP in at least 60 percent of cases and are treating for CAP instead.”