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Pneumonia guidelines might raise death rate

Guidelines on multidrug-resistant pneumonia could increase deaths

Louise Prime

Thursday, 20 January 2011

Compliance with guidelines on multidrug-resistant (MDR) pneumonia could lead to an increased risk of death from the disease in intensive care units, say researchers. In their paper published today Online First in The Lancet Infectious Diseases, they call for a reassessment of the guidelines from The American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA).

These guidelines say that hospital-acquired, ventilator-associated, and health-care associated pneumonias should be treated promptly – without waiting for culture results – with a triple regimen comprising two drugs against Gram-negative pathogens and one against meticillin-resistant Staphlococcus aureus (MRSA).

Data published since the ATS-IDSA guidelines have failed to show evidence of benefit from dual Gram-negative therapy over monotherapy. Researchers looked at the effect on outcomes of compliance with the recommended antibiotic regimen for 303 patients at risk for MDR pneumonia, in several centres in the US. Their definition of non-compliance included failure to use a second anti-Gram-negative drug (154 patients) and failure to use either a primary anti-Gram-negative drug (24 patients) or an anti-MRSA drug (24 patients).

They found that 65% of patients with MDR pneumonia who were treated according to the guidelines survived to 28 days. But in the non-compliant group, 79% of patients survived to 28 days. Severity of illness did not account for the difference.

The authors say: “Our results further question the need for combination Gram-negative empirical treatment for patients with pneumonia, even those who are severely ill and at risk of multi-drug resistant pathogens.”

They conclude: “[We] recommend that the planned, revised ATS-IDSA guidelines be reassessed before widespread implementation. Since the most common reason for non-compliance was failure to use a secondary anti-Gram-negative drug, we suggest a comparison of regimens employing MRSA treatment and single versus dual Gram-negative coverage.”

The author of an accompanying Comment questions the validity of the findings, but agrees that the recommended triple approach is not supported by the available evidence and is not necessarily correct: “All patients with septic shock, and probably severe sepsis, should receive dual coverage or triple coverage if MRSA is indicated. Whether all haemodynamically stable patients with nosocomial pneumonia need such a wide coverage is questionable.”

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