Effect of an Educational Intervention on the Management: RESULTS

Posted by James

A total of 37 patients were included in the study: 17 during phase 1 and 20 during phase 2 (Table 2). A total of 42 episodes of ventilator-associated pneumonia occurred: 20 (48%) during phase 1 and 22 (52%) during phase 2. Five (12%) of the 42 episodes were second episodes in patients who had completed a course of therapy for an earlier episode. Late-onset episodes were more common than early-onset episodes (29 [69%] and 13 [31%], respectively).

Figure 1. Pathogens isolated from patients with early- and late-onset ventilator-associated pneumonia diagnosed between April 1, 2006, and April 30, 2007. For some episodes, more than one organism was isolated. MSSA = methicillin-sensitive Staphylococcus aureus, MRSA = methicillin-resistant S. aureus.

The pathogens responsible for early- and late-onset ventilator-associated pneumonia at this institution over the entire 13-month period of the study are shown in Figure 1. MRSA was isolated in 4 (10%) of the 42 episodes, occurring primarily in patients with risk factors for MRSA, including injection drug use (2 episodes), homelessness (1 episode), and prolonged hospital stay (i.e., longer than 1 month) (1 episode). In 31% (9/29) of late-onset episodes of ventilator-associated pneumonia and 37% (11/30) of episodes in patients with risk factors for multidrug-resistance, organisms were isolated for which combination therapy might have been warranted to prevent emergence of resistance.
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Table 2. Demographic Characteristics of Patients

Characteristic	Mean ± SD* Phase 1(n= 17) Phase 2(n= 20)
Sex (no. and % men)	13 (76)	14 (70)
Age (years)	57 ±17	53 ± 18
Weight (kg)	86 ± 21	91 ± 38
APACHE II score	25 ± 6	21 ± 9
Duration of mechanical ventilation (days)	25 ± 21	17 ± 12
Length of stay in ICU (days)	29 ± 24	19 ± 13
Hospital length of stay (days)	43 ± 43	25 ± 13
No. (%) of deaths in ICU	4 (24)	2(10)
No. (%) of patients with risk factors for multidrug-
resistant pneumonia	14 (82)	16(80)
No. (%) of patients with immunodeficiency	2(12)	0
SD= standard deviation, APACHE = Acute Physiology and Chronic Health Evaluation, ICU = intensive care unit. *Unless indicated otherwise.

Table 3 summarizes the appropriateness of selection, dosing, route, and duration of therapy, as well as the timeliness of initiation of therapy.

De-escalation of therapy was not possible in 32 (76%) of the 42 episodes of ventilator-associated pneumonia, for the following reasons: de-escalation would have been inappropriate, given the pathogens identified (16 episodes [50%]); therapy had been initiat­ed on the basis of the culture results, so de-escalation did not apply (8 episodes [25%]); culture results were negative (4 episodes [12%]); and there were other potential sources of infection (4 episodes [12%]). Of the 10 episodes (5 in each phase) that were eligible for de-escalation, appropriate de-escalation of therapy increased from 60% (3/5 episodes) before to 100% (all 5 episodes) after the intervention (p = 0.11).
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Table 3. Appropriateness of Aspects of Empiric Antibiotic Therapy for Ventilator-Associated Pneumonia

Criterion	No.(%) ofEpisodes of Ventilator-Associated Pneumonia Phase 1(n= 20) Phase 2(n= 22)		p value
Appropriate selection
According to guidelines	7 (35)	13 (59)	0.11
According to local clinical practice	9 (45)	17 (77)	0.032
Appropriate dosing
According to guidelines	4 (20)	7 (33)*	0.33
According to local clinical practice	14 (70)	21 (95)	0.027
Appropriate route
According to guidelines	15 (75)	18 (82)	0.59
According to local clinical practice	20 (100)	22 (100)	>0.99
Timeliness	17 (85)	20 (91)	0.56
Appropriate duration	15 (79)t	11 (55)Ф	0.11
*Percentage calculated with a denominator of 21 because cefuroxime, which is not included in the guidelines, was used on the basis of culture results. tPercentage calculated with a denominator of 19 because one patient died while receiving antibiotics. ^Percentage calculated with a denominator of 20 because 2 patients died while receiving antibiotics.

Among patients who should have received a 7-day course of therapy, the proportion whose duration of therapy was appropriate increased from 67% (6/9 episodes) in phase 1 to 43% (6/14 episodes) in phase 2 (p = 0.27). Among episodes for which an extended duration of therapy was warranted because of growth of Pseudomonas or Acinetobacter or because of persistent signs and symptoms of infection, bacteremia, or immunocompromise, the proportion decreased from 90% (9/10) to 83% (5/6) (p = 0.70). The mean (min, max) duration of therapy overall appeared to improve after the educational intervention: from 12 days (7, 22) to 10 days (6, 15); the mean duration of therapy also seemed to improve for patients who required an extended course of therapy: from 15 (10, 22) days to 12 (8, 15) days. There was no change in the mean duration of therapy for patients who required a 7-day course of therapy (9 days in both phases).
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