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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

Published online by Cambridge University Press:  21 June 2017

Barbara E. Jones ,
Kevin Antoine Brown ,
Makoto M. Jones ,
Benedikt D. Huttner ,
Tom Greene ,
Brian C. Sauer ,
Karl Madaras-Kelly ,
Michael A. Rubin ,
Matthew Bidwell Goetz  and
Matthew H. Samore
Barbara E. Jones*
Affiliation:
VA Salt Lake City IDEAS Center, VA Salt Lake City Health Care System, Salt Lake City, Utah Division of Pulmonary & Critical Care Medicine, University of Utah, Salt Lake City, Utah
Kevin Antoine Brown
Affiliation:
VA Salt Lake City IDEAS Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
Makoto M. Jones
Affiliation:
VA Salt Lake City IDEAS Center, VA Salt Lake City Health Care System, Salt Lake City, Utah Division of Epidemiology, University of Utah, Salt Lake City, Utah
Benedikt D. Huttner
Affiliation:
VA Salt Lake City IDEAS Center, VA Salt Lake City Health Care System, Salt Lake City, Utah Division of Infectious Diseases and Infection Control Program, Geneva University Hospitals and Faculty of Medicine, University of Geneva
Tom Greene
Affiliation:
Division of Epidemiology, University of Utah, Salt Lake City, Utah
Brian C. Sauer
Affiliation:
VA Salt Lake City IDEAS Center, VA Salt Lake City Health Care System, Salt Lake City, Utah Division of Epidemiology, University of Utah, Salt Lake City, Utah
Karl Madaras-Kelly
Affiliation:
Boise Veterans Affairs Medical Center, Meridian, Idaho College of Pharmacy, Idaho State University, Meridian, Idaho
Michael A. Rubin
Affiliation:
VA Salt Lake City IDEAS Center, VA Salt Lake City Health Care System, Salt Lake City, Utah Division of Epidemiology, University of Utah, Salt Lake City, Utah
Matthew Bidwell Goetz
Affiliation:
Division of Infectious Disease, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California David Geffen School of Medicine at University of California–Los Angeles, Los Angeles, California
Matthew H. Samore
Affiliation:
VA Salt Lake City IDEAS Center, VA Salt Lake City Health Care System, Salt Lake City, Utah Division of Epidemiology, University of Utah, Salt Lake City, Utah
*
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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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

Information

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 38 , Issue 8 , August 2017 , pp. 937 - 944
Copyright
© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved 

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