Chest
Volume 122, Issue 1, July 2002, Pages 262-268
Journal home page for Chest

Clinical Investigations in Critical Care
Clinical Importance of Delays in the Initiation of Appropriate Antibiotic Treatment for Ventilator-Associated Pneumonia

https://doi.org/10.1378/chest.122.1.262Get rights and content

Study objectives

To determine the influence of initially delayed appropriate antibiotic treatment (IDAAT) on the outcomes of patients with ventilator-associated pneumonia (VAP).

Setting

Medical ICU of Barnes-Jewish Hospital, St. Louis, a university-affiliated urban teaching hospital.

Patients

One hundred seven consecutive patients receiving mechanical ventilation and antibiotic treatment for VAP.

Interventions

Prospective patient surveillance and data collection.

Measurements and results

All 107 patients eventually received treatment with an antibiotic regimen that was shown in vitro to be active against the bacterial pathogens isolated from their respiratory secretions. Thirty-three patients (30.8%) received antibiotic treatment that was delayed for ≥ 24 h after initially meeting diagnostic criteria for VAP. These patients were classified as receiving IDAAT. The most common reason for the administration of IDAAT was a delay in writing the antibiotic orders (n = 25; 75.8%). The mean time (± SD) interval from initially meeting the diagnostic criteria for VAP until the administration of antibiotic treatment was 28.6 ± 5.8 h among patients classified as receiving IDAAT, compared to 12.5 ± 4.2 h for all other patients (p < 0.001). Forty-four patients (41.1%) with VAP died during their hospitalization. Increasing APACHE (acute physiology and chronic health evaluation) II scores (adjusted odds ratio, 1.13; 95% confidence interval, 1.09 to 1.18; p < 0.001), presence of malignancy (adjusted odds ratio, 3.20; 95% confidence interval, 1.79 to 5.71; p = 0.044), and the administration of IDAAT (adjusted odds ratio, 7.68; 95% confidence interval, 4.50 to 13.09; p < 0.001) were identified as risk factors independently associated with hospital mortality by logistic regression analysis.

Conclusion

These data suggest that patients classified as receiving IDAAT are at greater risk for hospital mortality. Clinicians should avoid delaying the administration of appropriate antibiotic treatment to patients with VAP in order to minimize their risk of mortality.

Section snippets

Study Location and Patients

This study was conducted at a university-affiliated urban teaching hospital, Barnes-Jewish Hospital (1,000 beds). During a 1-year period (February 2000 through February 2001), all patients receiving mechanical ventilation in the medical ICU were eligible for this investigation. Patients were excluded from participation if they were transferred to the medical ICU from another hospital while receiving mechanical ventilation or were admitted to the medical ICU temporarily due to unavailability of

Patients

A total of 107 consecutive patients receiving mechanical ventilation and antibiotic treatment for VAP were evaluated. The mean age of the patients was 56.6 ± 16.8 years (range, 17 to 89 years), and the mean APACHE II score of the study cohort was 24.6 ± 8.1 (range, 8 to 47). Sixty-four patients (59.8%) were women, and 43 patients (40.2%) were men. The indications for mechanical ventilation included exacerbations of COPD (n = 15), congestive heart failure (n = 6), community-acquired pneumonia (n

Discussion

We found a statistically significant association between the administration of IDAAT and hospital mortality for patients with VAP. Multiple logistic regression analysis identified IDAAT, increasing severity of illness as measured by APACHE II scores, and the presence of underlying malignancy as important determinants of hospital mortality for this patient cohort. The most common reason identified for the administration of IDAAT was a delay in writing the orders for antibiotic treatment after

References (26)

  • MH Kollef et al.

    The influence of mini-BAL cultures on patient outcomes: implications for the antibiotic management of ventilator-associated pneumonia

    Chest

    (1998)
  • MH Kollef

    Inadequate antimicrobial treatment: an important determinant of outcome for hospitalized patients

    Clin Infect Dis

    (2000)
  • WA Knaus et al.

    APACHE II: A severity of disease classification system

    Crit Care Med

    (1985)
  • Cited by (0)

    This work was supported in part by the Barnes-Jewish Hospital Foundation.

    View full text