Effect of an Educational Intervention on the Management: METHODS part 2

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Two methods were also used to evaluate dosing. First, empiric dosing for agents available at this institution was compared with the dosing recommended in the guidelines (ceftazidime 2 g q8h, meropenem 1 g q8h, piperacillin-tazobactam 4.5 g q6h, gentamicin 7 mg/kg per day, ciprofloxacin 400 mg q8h, and vancomycin 15 mg/kg q12h). Then, empiric dosing was compared with dosing considered clinically appropriate on the basis of practice at local hospitals; these locally accepted dosing practices did not have an evidentiary basis. Regimens considered clinically appropriate that were different from those recommended in the guidelines included ciprofloxacin 400 mg q12h and, for patients with body weight less than 100 kg, cefotaxime and ceftazidime 1 g q8h and piperacillin-tazobactam 3.375 g q6h. Dosing adjustments for renal dysfunction were considered in evaluating the appropriateness of dosing.

The guidelines defined IV therapy as the only appropriate empiric route of therapy; however, oral therapy was considered clinically appropriate if the patient was hemodynamically stable (not requiring vasopressor therapy) and was able to tolerate oral or nasogastric feeding and antibiotics with good oral bioavailability (i.e., ciprofloxacin) were being used.
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Therapy was considered timely if it was initiated within 24 h after diagnosis of ventilator-associated pneumonia.

De-escalation (narrowing of therapy on the basis of culture data) was considered appropriate if the therapy was narrowed within 24 h after positive culture results became available. In addition, therapy could be de-escalated if patients had no other potential concurrent sources of infection that might have required therapy.

Table 1. Risk Factors for Multidrug-Resistant Pathogens Causing Hospital-Acquired, Health-Care-Associated, and Ventilator-Associated Pneumonia
Antimicrobial therapy in preceding 90 days Current hospital stay of 5 days or more
High frequency of antibiotic resistance in the community or in the specific hospital unit Presence of risk factors for health-care-associated pneumonia: Hospital stay for 2 days or more in the preceding 90 days Residence in a nursing home or extended care facility Home infusion therapy (including antibiotics) Long-term dialysis within the preceding 30 days Home wound care
Family member with multidrug-resistant pathogen Immunosuppressive disease and/or therapy

Appropriate duration of therapy was defined as 7 days ± 1 day unless Pseudomonas aeruginosa or Acinetobacter sp. was cultured, in which case the appropriate duration of therapy was defined as 14 days ± 1 day, or unless the patient was immunocompro- mised, had bacteremia, or had persistent signs and symptoms consistent with active infection, in which case it was appropriate to continue therapy until clinical resolution. canada drugs online

The results from phases 1 and 2 were compared using the x2 test. Data were analyzed using the Quick- Calcs Online Calculator for Scientists (GraphPad Soft­ware). A p value less than 0.05 was deemed significant.