Suzanne Ward

Experience with a clinical guideline for the treatment of ventilator-associated pneumonia.

Objective To evaluate a clinical guideline for the treatment of ventilator-associated pneumonia. Design Prospective before-and-after study design. Setting A medical intensive care unit from a university-affiliated, urban teaching hospital. Patients Between April 1999 and January 2000, 102 patients were prospectively evaluated. Interventions Prospective patient surveillance, data collection, and implementation of an antimicrobial guideline for the treatment of ventilator-associated pneumonia. Measurements and Main Results The main outcome evaluated was the initial administration of adequate antimicrobial treatment as determined by respiratory tract cultures. Secondary outcomes evaluated included the duration of antimicrobial treatment for ventilator-associated pneumonia, hospital mortality, intensive care unit and hospital lengths of stay, and the occurrence of a second episode of ventilator-associated pneumonia. Fifty consecutive patients with ventilator-associated pneumonia were evaluated in the before period and 52 consecutive patients with ventilator-associated pneumonia were evaluated in the after period. Severity of illness using Acute Physiology and Chronic Health Evaluation II (25.8 ± 5.7 vs. 25.4 ± 8.1, p = .798) and the clinical pulmonary infection scores (6.6 ± 1.0 vs. 6.9 ± 1.2, p = .105) were similar for patients during the two treatment periods. The initial administration of adequate antimicrobial treatment was statistically greater during the after period compared with the before period (94.2% vs. 48.0%, p < .001). The duration of antimicrobial treatment was statistically shorter during the after period compared with the before period (8.6 ± 5.1 days vs. 14.8 ± 8.1 days, p < .001). A second episode of ventilator-associated pneumonia occurred statistically less often among patients in the after period (7.7% vs. 24.0%, p = .030). Conclusions The application of a clinical guideline for the treatment of ventilator-associated pneumonia can increase the initial administration of adequate antimicrobial treatment and decrease the overall duration of antibiotic treatment. These findings suggest that similar types of guidelines employing local microbiological data can be used to improve overall antibiotic utilization for the treatment of ventilator-associated pneumonia.

Inadequate treatment of nosocomial infections is associated with certain empiric antibiotic choices.

ObjectiveThe purpose of this study was to determine the impact of scheduled changes of antibiotic classes, used for the empirical treatment of suspected or documented Gram-negative bacterial infections, on the occurrence of inadequate antimicrobial treatment of nosocomial infections. DesignProspective observational study. SettingMedical (19-bed) and surgical (18-bed) intensive care units in an urban teaching hospital. PatientsA total of 3,668 patients requiring intensive care unit admission were prospectively evaluated during three consecutive time periods. InterventionsDuring each time period, one antibiotic class was selected for the empirical treatment of Gram-negative bacterial infections as follows: time period 1 (baseline period) (1,323 patients), ceftazidime; time period 2 (1,243 patients), ciprofloxacin; and time period 3 (1,102 patients), cefepime. Measurements and Main ResultsThe overall administration of inadequate antimicrobial treatment for nosocomial infections decreased during the course of the study (6.1%, 4.7%, and 4.5%;p = .15). This was primarily because of a statistically significant decrease in the administration of inadequate antibiotic treatment for Gram-negative bacterial infections (4.4%, 2.1%, and 1.6%;p < .001). There were no statistically significant differences in the overall hospital mortality rate among the three time periods (15.6%, 16.4%, and 16.2%;p = .828) despite a significant increase in severity of illness as measured with Acute Physiology and Chronic Health Evaluation (APACHE) II scores (15.3 ± 7.6, 15.7 ± 8.0, and 20.7 ± 8.6;p < .001). The hospital mortality rate decreased significantly during time period 3 (20.6%) compared with time period 1 (28.4%;p < .001) and time period 2 (29.5%;p < .001) for patients with an APACHE II score ≥15. ConclusionsThese data suggest that scheduled changes of antibiotic classes for the empirical treatment of Gram-negative bacterial infections can reduce the occurrence of inadequate antibiotic treatment for nosocomial infections. Reducing inadequate antibiotic administration may improve the outcomes of critically ill patients with APACHE II scores ≥15.

The influence of access to a private attending physician on the withdrawal of life-sustaining therapies in the intensive care unit

OBJECTIVE To assess the influence of patient access to a private attending physician on the withdrawal of life-sustaining therapies in a medical intensive care unit (ICU). DESIGN Prospective cohort study. SETTING A university-affiliated teaching hospital. PATIENTS A total of 501 consecutive patients admitted to the medical ICU during a 5-month period. INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS Among patients dying in the medical ICU, those without a private attending physician (n = 26) were statistically more likely to undergo the active withdrawal of life-sustaining therapies than patients with a private attending physician (n = 87) (80.8% vs. 29.9%; relative risk = 2.70; 95% confidence interval = 1.86-3.92; p < .001). Despite having similar predicted mortality rates by Acute Physiology and Chronic Health Evaluation II score (60.5% +/- 27.0% vs. 66.1% +/- 21.3%; p = .280), patients dying in the medical ICU without a private attending physician had statistically shorter hospital and ICU lengths of stay, a shorter duration of mechanical ventilation, and fewer total hospital costs and charges compared with patients with access to a private attending physician. Multiple logistic regression analysis, controlling for severity of illness, demographic characteristics, and patient diagnoses, demonstrated that lack of access to a private attending physician (adjusted odds ratio = 23.10; 95% confidence interval = 9.10-58.57; p < .001) and the presence of a do-not-resuscitate order while in the ICU (adjusted odds ratio = 7.33; 95% confidence interval = 3.69-14.54; p = .004) were the only variables independently associated with the withdrawal of life-sustaining therapies before death. CONCLUSIONS Patients dying in a medical ICU setting without access to a private attending physician are more likely to undergo the active withdrawal of life-sustaining therapies before death than patients with a private attending physician. Health care providers should be aware of possible variations in the practice of withdrawal of life-sustaining therapies in their ICUs based on this patient characteristic.