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Ventilator-Associated Pneumonia: Overdiagnosis and Treatment Are Common in Medical and Surgical Intensive Care Units

Published online by Cambridge University Press:  10 May 2016

Veronique Nussenblatt ,
Edina Avdic ,
Sean Berenholtz ,
Elizabeth Daugherty ,
Eric Hadhazy ,
Pamela A. Lipsett ,
Lisa L. Maragakis ,
Trish M. Perl ,
Kathleen Speck  and
Sandra M. Swoboda
...Show all authors
Veronique Nussenblatt
Affiliation:
Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
Edina Avdic
Affiliation:
Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
Sean Berenholtz
Affiliation:
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
Elizabeth Daugherty
Affiliation:
Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
Eric Hadhazy
Affiliation:
Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
Pamela A. Lipsett
Affiliation:
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
Lisa L. Maragakis
Affiliation:
Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
Trish M. Perl
Affiliation:
Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
Kathleen Speck
Affiliation:
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
Sandra M. Swoboda
Affiliation:
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
Wendy Ziai
Affiliation:
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
Sara E. Cosgrove*
Affiliation:
Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
*
Hospital Epidemiology and Infection Control and Antimicrobial Stewardship Program, Johns Hopkins Hospital, 600 North Wolfe Street, Osier 425, Baltimore, MD 21287 (scosgrol@jhmi.edu)
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Abstract

Objective.

Diagnosing ventilator-associated pneumonia (VAP) is difficult, and misdiagnosis can lead to unnecessary and prolonged antibiotic treatment. We sought to quantify and characterize unjustified antimicrobial use for VAP and identify risk factors for continuation of antibiotics in patients without VAP after 3 days.

Methods.

Patients suspected of having VAP were identified in 6 adult intensive care units (ICUs) over 1 year. A multidisciplinary adjudication committee determined whether the ICU team's VAP diagnosis and therapy were justified, using clinical, microbiologic, and radiographic data at diagnosis and on day 3. Outcomes included the proportion of VAP events misdiagnosed as and treated for VAP on days 1 and 3 and risk factors for the continuation of antibiotics in patients without VAP after day 3.

Results.

Two hundred thirty-one events were identified as possible VAP by the ICUs. On day 1, 135 (58.4%) of them were determined to not have VAP by the committee. Antibiotics were continued for 120 (76%) of 158 events without VAP on day 3. After adjusting for acute physiology and chronic health evaluation II score and requiring vasopressors on day 1, sputum culture collection on day 3 was significantly associated with antibiotic continuation in patients without VAP. Patients without VAP or other infection received 1,183 excess days of antibiotics during the study.

Conclusions.

Overdiagnosis and treatment of VAP was common in this study and led to 1,183 excess days of antibiotics in patients with no indication for antibiotics. Clinical differences between non-VAP patients who had antibiotics continued or discontinued were minimal, suggesting that clinician preferences and behaviors contribute to unnecessary prescribing.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 35 , Issue 3 , March 2014 , pp. 278 - 284
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2014

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