A Therapeutic Strategy for All Pneumonia Patients: A 3-Year Prospective Multicenter Cohort Study Using Risk Factors for Multidrug-resistant Pathogens to Select Initial Empiric Therapy

Takaya Maruyama, Takao Fujisawa, Tadashi Ishida, Akihiro Ito, Yoshitaka Oyamada, Kazuyuki Fujimoto, Masamichi Yoshida, Hikaru Maeda, Naoyuki Miyashita, Hideaki Nagai, Yoshifumi Imamura, Nobuaki Shime, Shoji Suzuki, Masaru Amishima, Futoshi Higa, Hiroyasu Kobayashi, Shigeru Suga, Kiyoyuki Tsutsui, Shigeru Kohno, Veronica BritoMichael S. Niederman

Research output: Contribution to journalArticle

4 Citations (Scopus)

Abstract

Background Empiric therapy of pneumonia is currently based on the site of acquisition (community or hospital), but could be chosen, based on risk factors for multidrug-resistant (MDR) pathogens, independent of site of acquisition. Methods We prospectively applied a therapeutic algorithm based on MDR risks, in a multicenter cohort study of 1089 patients with 656 community-acquired pneumonia (CAP), 238 healthcare-associated pneumonia (HCAP), 140 hospital-acquired pneumonia (HAP), or 55 ventilator-associated pneumonia (VAP). Results Approximately 83% of patients were treated according to the algorithm, with 4.3% receiving inappropriate therapy. The frequency of MDR pathogens varied, respectively, with VAP (50.9%), HAP (27.9%), HCAP (10.9%), and CAP (5.2%). Those with ≥2 MDR risks had MDR pathogens more often than those with 0-1 MDR risk (25.8% vs 5.3%, P <.001). The 30-day mortality rates were as follows: VAP (18.2%), HAP (13.6%), HCAP (6.7%), and CAP (4.7%), and were lower in patients with 0-1 MDR risks than in those with ≥2 MDR risks (4.5% vs 12.5%, P <.001). In multivariate logistic regression analysis, 5 risk factors (advanced age, hematocrit <30%, malnutrition, dehydration, and chronic liver disease), as well as hypotension and inappropriate therapy were significantly correlated with 30-day mortality, whereas the classification of pneumonia type (VAP, HAP, HCAP, CAP) was not. Conclusions Individual MDR risk factors can be used in a unified algorithm to guide and simplify empiric therapy for all pneumonia patients, and were more important than the classification of site of pneumonia acquisition in determining 30-day mortality. Clinical Trials Registration JMA-IIA00146.

Original languageEnglish
Pages (from-to)1080-1088
Number of pages9
JournalClinical Infectious Diseases
Volume68
Issue number7
DOIs
Publication statusPublished - 2019 Mar 19

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Multicenter Studies
Pneumonia
Cohort Studies
Ventilator-Associated Pneumonia
Therapeutics
Delivery of Health Care
Mortality
Community Hospital
Dehydration
Hematocrit
Malnutrition
Hypotension
Liver Diseases
Chronic Disease
Logistic Models
Regression Analysis

Keywords

  • antibiotic therapy
  • community-acquired pneumonia
  • guidelines
  • nosocomial pneumonia
  • pneumonia

ASJC Scopus subject areas

  • Microbiology (medical)
  • Infectious Diseases

Cite this

A Therapeutic Strategy for All Pneumonia Patients : A 3-Year Prospective Multicenter Cohort Study Using Risk Factors for Multidrug-resistant Pathogens to Select Initial Empiric Therapy. / Maruyama, Takaya; Fujisawa, Takao; Ishida, Tadashi; Ito, Akihiro; Oyamada, Yoshitaka; Fujimoto, Kazuyuki; Yoshida, Masamichi; Maeda, Hikaru; Miyashita, Naoyuki; Nagai, Hideaki; Imamura, Yoshifumi; Shime, Nobuaki; Suzuki, Shoji; Amishima, Masaru; Higa, Futoshi; Kobayashi, Hiroyasu; Suga, Shigeru; Tsutsui, Kiyoyuki; Kohno, Shigeru; Brito, Veronica; Niederman, Michael S.

In: Clinical Infectious Diseases, Vol. 68, No. 7, 19.03.2019, p. 1080-1088.

Research output: Contribution to journalArticle

Maruyama, T, Fujisawa, T, Ishida, T, Ito, A, Oyamada, Y, Fujimoto, K, Yoshida, M, Maeda, H, Miyashita, N, Nagai, H, Imamura, Y, Shime, N, Suzuki, S, Amishima, M, Higa, F, Kobayashi, H, Suga, S, Tsutsui, K, Kohno, S, Brito, V & Niederman, MS 2019, 'A Therapeutic Strategy for All Pneumonia Patients: A 3-Year Prospective Multicenter Cohort Study Using Risk Factors for Multidrug-resistant Pathogens to Select Initial Empiric Therapy', Clinical Infectious Diseases, vol. 68, no. 7, pp. 1080-1088. https://doi.org/10.1093/cid/ciy631
Maruyama, Takaya ; Fujisawa, Takao ; Ishida, Tadashi ; Ito, Akihiro ; Oyamada, Yoshitaka ; Fujimoto, Kazuyuki ; Yoshida, Masamichi ; Maeda, Hikaru ; Miyashita, Naoyuki ; Nagai, Hideaki ; Imamura, Yoshifumi ; Shime, Nobuaki ; Suzuki, Shoji ; Amishima, Masaru ; Higa, Futoshi ; Kobayashi, Hiroyasu ; Suga, Shigeru ; Tsutsui, Kiyoyuki ; Kohno, Shigeru ; Brito, Veronica ; Niederman, Michael S. / A Therapeutic Strategy for All Pneumonia Patients : A 3-Year Prospective Multicenter Cohort Study Using Risk Factors for Multidrug-resistant Pathogens to Select Initial Empiric Therapy. In: Clinical Infectious Diseases. 2019 ; Vol. 68, No. 7. pp. 1080-1088.
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abstract = "Background Empiric therapy of pneumonia is currently based on the site of acquisition (community or hospital), but could be chosen, based on risk factors for multidrug-resistant (MDR) pathogens, independent of site of acquisition. Methods We prospectively applied a therapeutic algorithm based on MDR risks, in a multicenter cohort study of 1089 patients with 656 community-acquired pneumonia (CAP), 238 healthcare-associated pneumonia (HCAP), 140 hospital-acquired pneumonia (HAP), or 55 ventilator-associated pneumonia (VAP). Results Approximately 83{\%} of patients were treated according to the algorithm, with 4.3{\%} receiving inappropriate therapy. The frequency of MDR pathogens varied, respectively, with VAP (50.9{\%}), HAP (27.9{\%}), HCAP (10.9{\%}), and CAP (5.2{\%}). Those with ≥2 MDR risks had MDR pathogens more often than those with 0-1 MDR risk (25.8{\%} vs 5.3{\%}, P <.001). The 30-day mortality rates were as follows: VAP (18.2{\%}), HAP (13.6{\%}), HCAP (6.7{\%}), and CAP (4.7{\%}), and were lower in patients with 0-1 MDR risks than in those with ≥2 MDR risks (4.5{\%} vs 12.5{\%}, P <.001). In multivariate logistic regression analysis, 5 risk factors (advanced age, hematocrit <30{\%}, malnutrition, dehydration, and chronic liver disease), as well as hypotension and inappropriate therapy were significantly correlated with 30-day mortality, whereas the classification of pneumonia type (VAP, HAP, HCAP, CAP) was not. Conclusions Individual MDR risk factors can be used in a unified algorithm to guide and simplify empiric therapy for all pneumonia patients, and were more important than the classification of site of pneumonia acquisition in determining 30-day mortality. Clinical Trials Registration JMA-IIA00146.",
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T2 - A 3-Year Prospective Multicenter Cohort Study Using Risk Factors for Multidrug-resistant Pathogens to Select Initial Empiric Therapy

AU - Maruyama, Takaya

AU - Fujisawa, Takao

AU - Ishida, Tadashi

AU - Ito, Akihiro

AU - Oyamada, Yoshitaka

AU - Fujimoto, Kazuyuki

AU - Yoshida, Masamichi

AU - Maeda, Hikaru

AU - Miyashita, Naoyuki

AU - Nagai, Hideaki

AU - Imamura, Yoshifumi

AU - Shime, Nobuaki

AU - Suzuki, Shoji

AU - Amishima, Masaru

AU - Higa, Futoshi

AU - Kobayashi, Hiroyasu

AU - Suga, Shigeru

AU - Tsutsui, Kiyoyuki

AU - Kohno, Shigeru

AU - Brito, Veronica

AU - Niederman, Michael S.

PY - 2019/3/19

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N2 - Background Empiric therapy of pneumonia is currently based on the site of acquisition (community or hospital), but could be chosen, based on risk factors for multidrug-resistant (MDR) pathogens, independent of site of acquisition. Methods We prospectively applied a therapeutic algorithm based on MDR risks, in a multicenter cohort study of 1089 patients with 656 community-acquired pneumonia (CAP), 238 healthcare-associated pneumonia (HCAP), 140 hospital-acquired pneumonia (HAP), or 55 ventilator-associated pneumonia (VAP). Results Approximately 83% of patients were treated according to the algorithm, with 4.3% receiving inappropriate therapy. The frequency of MDR pathogens varied, respectively, with VAP (50.9%), HAP (27.9%), HCAP (10.9%), and CAP (5.2%). Those with ≥2 MDR risks had MDR pathogens more often than those with 0-1 MDR risk (25.8% vs 5.3%, P <.001). The 30-day mortality rates were as follows: VAP (18.2%), HAP (13.6%), HCAP (6.7%), and CAP (4.7%), and were lower in patients with 0-1 MDR risks than in those with ≥2 MDR risks (4.5% vs 12.5%, P <.001). In multivariate logistic regression analysis, 5 risk factors (advanced age, hematocrit <30%, malnutrition, dehydration, and chronic liver disease), as well as hypotension and inappropriate therapy were significantly correlated with 30-day mortality, whereas the classification of pneumonia type (VAP, HAP, HCAP, CAP) was not. Conclusions Individual MDR risk factors can be used in a unified algorithm to guide and simplify empiric therapy for all pneumonia patients, and were more important than the classification of site of pneumonia acquisition in determining 30-day mortality. Clinical Trials Registration JMA-IIA00146.

AB - Background Empiric therapy of pneumonia is currently based on the site of acquisition (community or hospital), but could be chosen, based on risk factors for multidrug-resistant (MDR) pathogens, independent of site of acquisition. Methods We prospectively applied a therapeutic algorithm based on MDR risks, in a multicenter cohort study of 1089 patients with 656 community-acquired pneumonia (CAP), 238 healthcare-associated pneumonia (HCAP), 140 hospital-acquired pneumonia (HAP), or 55 ventilator-associated pneumonia (VAP). Results Approximately 83% of patients were treated according to the algorithm, with 4.3% receiving inappropriate therapy. The frequency of MDR pathogens varied, respectively, with VAP (50.9%), HAP (27.9%), HCAP (10.9%), and CAP (5.2%). Those with ≥2 MDR risks had MDR pathogens more often than those with 0-1 MDR risk (25.8% vs 5.3%, P <.001). The 30-day mortality rates were as follows: VAP (18.2%), HAP (13.6%), HCAP (6.7%), and CAP (4.7%), and were lower in patients with 0-1 MDR risks than in those with ≥2 MDR risks (4.5% vs 12.5%, P <.001). In multivariate logistic regression analysis, 5 risk factors (advanced age, hematocrit <30%, malnutrition, dehydration, and chronic liver disease), as well as hypotension and inappropriate therapy were significantly correlated with 30-day mortality, whereas the classification of pneumonia type (VAP, HAP, HCAP, CAP) was not. Conclusions Individual MDR risk factors can be used in a unified algorithm to guide and simplify empiric therapy for all pneumonia patients, and were more important than the classification of site of pneumonia acquisition in determining 30-day mortality. Clinical Trials Registration JMA-IIA00146.

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KW - guidelines

KW - nosocomial pneumonia

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