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Variation in Empiric Coverage Versus Detection of Methicillin-Resistant Staphylococcus aureus and Pseudomonas aeruginosa in Hospitalizations for Community-Onset Pneumonia Across 128 US Veterans Affairs Medical Centers

  • Barbara E. Jones (a1) (a2), Kevin Antoine Brown (a1), Makoto M. Jones (a1) (a3), Benedikt D. Huttner (a1) (a4), Tom Greene (a3), Brian C. Sauer (a1) (a3), Karl Madaras-Kelly (a5) (a6), Michael A. Rubin (a1) (a3), Matthew Bidwell Goetz (a7) (a8) and Matthew H. Samore (a1) (a3)...

Abstract

OBJECTIVE

To examine variation in antibiotic coverage and detection of resistant pathogens in community-onset pneumonia.

DESIGN

Cross-sectional study.

SETTING

A total of 128 hospitals in the Veterans Affairs health system.

PARTICIPANTS

Hospitalizations with a principal diagnosis of pneumonia from 2009 through 2010.

METHODS

We examined proportions of hospitalizations with empiric antibiotic coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (PAER) and with initial detection in blood or respiratory cultures. We compared lowest- versus highest-decile hospitals, and we estimated adjusted probabilities (AP) for patient- and hospital-level factors predicting coverage and detection using hierarchical regression modeling.

RESULTS

Among 38,473 hospitalizations, empiric coverage varied widely across hospitals (MRSA lowest vs highest, 8.2% vs 42.0%; PAER lowest vs highest, 13.9% vs 44.4%). Detection rates also varied (MRSA lowest vs highest, 0.5% vs 3.6%; PAER lowest vs highest, 0.6% vs 3.7%). Whereas coverage was greatest among patients with recent hospitalizations (AP for anti-MRSA, 54%; AP for anti-PAER, 59%) and long-term care (AP for anti-MRSA, 60%; AP for anti-PAER, 66%), detection was greatest in patients with a previous history of a positive culture (AP for MRSA, 7.9%; AP for PAER, 11.9%) and in hospitals with a high prevalence of the organism in pneumonia (AP for MRSA, 3.9%; AP for PAER, 3.2%). Low hospital complexity and rural setting were strong negative predictors of coverage but not of detection.

CONCLUSIONS

Hospitals demonstrated widespread variation in both coverage and detection of MRSA and PAER, but probability of coverage correlated poorly with probability of detection. Factors associated with empiric coverage (eg, healthcare exposure) were different from those associated with detection (eg, microbiology history). Providing microbiology data during empiric antibiotic decision making could better align coverage to risk for resistant pathogens and could promote more judicious use of broad-spectrum antibiotics.

Infect Control Hosp Epidemiol 2017;38:937–944

Copyright

Corresponding author

Address correspondence to Barbara E. Jones, MD, MSc, Division of Pulmonary and Critical Care Medicine, Salt Lake City Veterans Affairs Health System, 30N 1900 E 701 Wintrobe, Salt Lake City, UT 84132 (Barbara.jones@hsc.utah.edu).

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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
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