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Impact of Inappropriate Empiric Treatment of Acinetobacter Baumannii Pneumonia and Sepsis on Hospital Mortality
Chest Infections SESSION TITLE: Atypical Chest Infections SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, October 23, 2016 at 01:30 PM - 03:00 PM
Impact of Inappropriate Empiric Treatment of Acinetobacter Baumannii Pneumonia and Sepsis on Hospital Mortality Marya Zilberberg MD* Brian Nathanson PhD Kate Sulham MPH Weihong Fan MS; and Andrew Shorr MD University of Massachusetts, Amherst, MA PURPOSE: Inappropriate empiric therapy (IET) for severe bacterial infections increases the risk for death. Since there are little data on this relationship in severe Acinetobacter baumannii (AB) infections, we sought to explore it in a large US database.
CHEST INFECTIONS
METHODS: We conducted a retrospective cohort study in the Premier Research database (2009-2013) of 175 US hospitals. We included all adult patients admitted with pneumonia or sepsis as principal diagnosis, or as a secondary diagnosis in the setting of respiratory failure, along with antibiotic administration within 2 days of admission. Patients with hospital-onset infection or transfers from other acute care facilities were excluded. Only culture confirmed infections were included. IET was present if no antibiotic administered within 2 days of obtaining positive culture covered the corresponding organism. Resistance to >3 classes of antibiotics defined multidrug resistant (MDR)-AB. We classified infection as healthcare-associated (HCA) if one or more of the following was present: 1) prior hospitalization within 90 days of the index hospitalization, 2) hemodialysis, 3) admission from a long-term care facility, 4) immune suppression. All other infections were considered community-acquired. We used logistic regression to compute the adjusted effect of IET on the risk of hospital death. RESULTS: Among 1,098 patients, 2/3 (n¼719) received IET. Those receiving IET did not differ from the non-IET patients with respect to age, gender, ethnicity, chronic disease burden or severity of their acute illness. Those receiving IET were more likely than non-IET to be admitted from an extended care facility (24.1% vs. 18.2%) or emergency room (20.6% vs. 16.6%, p¼0.022) and to have HCA (64.5% vs. 58.6%, p¼0.053). MDR-AB was isolated far more frequently in patients treated inappropriately (96.4%) than non-IET subjects (57.3%, p<0.001). Unadjusted hospital mortality was higher in patients receiving IET than non-IET (23.6% vs. 16.6%, p¼0.007). IET exposure was associated with higher adjusted hospital mortality (relative risk ratio 1.8, 95% CI 1.4, 2.3 p<0.001) relative to non-IET. CONCLUSIONS: In this large US cohort of AB infections, MDR-AB was common and the majority of the patients, irrespective of AB susceptibilities, received IET. IET nearly doubled the risk of death. CLINICAL IMPLICATIONS: Local resistance patterns should inform empiric therapy choices. More accurate targeting of empiric treatment may improve outcomes in AB pneumonia and sepsis. DISCLOSURE: Marya Zilberberg: Grant monies (from industry related sources): The Medicines Company, Grant monies (from industry related sources): Tetraphase, Grant monies (from industry related sources): Merck, Consultant fee, speaker bureau, advisory committee, etc.: Merck, Grant monies (from industry related sources): Theravance, Grant monies (from industry related sources): Pfizer Brian Nathanson: Grant monies (from industry related sources): The Medicines Company Kate Sulham: Employee: The Medicines Company Weihong Fan: Employee: The Medicines Company Andrew Shorr: Grant monies (from industry related sources): The Medicines Company, Grant monies (from industry related sources): Pfizer, Grant monies (from industry related sources): Tetraphase, Grant monies (from industry related sources): Theravance, Grant monies (from industry related sources): Merck No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.123
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
114A
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150#4S CHEST OCTOBER 2016
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Impact of Inappropriate Empiric Treatment of Acinetobacter Baumannii Pneumonia and Sepsis on Hospital Mortality Marya Zilberberg MD* Brian Nathanson PhD Kate Sulham MPH Weihong Fan MS; and Andrew Shorr MD University of Massachusetts, Amherst, MA PURPOSE: Inappropriate empiric therapy (IET) for severe bacterial infections increases the risk for death. Since there are little data on this relationship in severe Acinetobacter baumannii (AB) infections, we sought to explore it in a large US database.
CHEST INFECTIONS
METHODS: We conducted a retrospective cohort study in the Premier Research database (2009-2013) of 175 US hospitals. We included all adult patients admitted with pneumonia or sepsis as principal diagnosis, or as a secondary diagnosis in the setting of respiratory failure, along with antibiotic administration within 2 days of admission. Patients with hospital-onset infection or transfers from other acute care facilities were excluded. Only culture confirmed infections were included. IET was present if no antibiotic administered within 2 days of obtaining positive culture covered the corresponding organism. Resistance to >3 classes of antibiotics defined multidrug resistant (MDR)-AB. We classified infection as healthcare-associated (HCA) if one or more of the following was present: 1) prior hospitalization within 90 days of the index hospitalization, 2) hemodialysis, 3) admission from a long-term care facility, 4) immune suppression. All other infections were considered community-acquired. We used logistic regression to compute the adjusted effect of IET on the risk of hospital death. RESULTS: Among 1,098 patients, 2/3 (n¼719) received IET. Those receiving IET did not differ from the non-IET patients with respect to age, gender, ethnicity, chronic disease burden or severity of their acute illness. Those receiving IET were more likely than non-IET to be admitted from an extended care facility (24.1% vs. 18.2%) or emergency room (20.6% vs. 16.6%, p¼0.022) and to have HCA (64.5% vs. 58.6%, p¼0.053). MDR-AB was isolated far more frequently in patients treated inappropriately (96.4%) than non-IET subjects (57.3%, p<0.001). Unadjusted hospital mortality was higher in patients receiving IET than non-IET (23.6% vs. 16.6%, p¼0.007). IET exposure was associated with higher adjusted hospital mortality (relative risk ratio 1.8, 95% CI 1.4, 2.3 p<0.001) relative to non-IET. CONCLUSIONS: In this large US cohort of AB infections, MDR-AB was common and the majority of the patients, irrespective of AB susceptibilities, received IET. IET nearly doubled the risk of death. CLINICAL IMPLICATIONS: Local resistance patterns should inform empiric therapy choices. More accurate targeting of empiric treatment may improve outcomes in AB pneumonia and sepsis. DISCLOSURE: Marya Zilberberg: Grant monies (from industry related sources): The Medicines Company, Grant monies (from industry related sources): Tetraphase, Grant monies (from industry related sources): Merck, Consultant fee, speaker bureau, advisory committee, etc.: Merck, Grant monies (from industry related sources): Theravance, Grant monies (from industry related sources): Pfizer Brian Nathanson: Grant monies (from industry related sources): The Medicines Company Kate Sulham: Employee: The Medicines Company Weihong Fan: Employee: The Medicines Company Andrew Shorr: Grant monies (from industry related sources): The Medicines Company, Grant monies (from industry related sources): Pfizer, Grant monies (from industry related sources): Tetraphase, Grant monies (from industry related sources): Theravance, Grant monies (from industry related sources): Merck No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.123
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
114A
[
150#4S CHEST OCTOBER 2016
]