Implementation of guidelines for management of possible multidrug-resistant XXXX in intensive care: an observational, multicentre cohort study.

@entity1 @entity3256 @entity55 @entity794 @entity1514 @entity204 @entity166
BACKGROUND: The American @entity1514 Society and @entity166 Society of America provide guidelines for management of hospital-acquired, ventilator-associated, and health-care-associated @entity55 , consisting of empirical antibiotic regimens for @entity1 at risk for multidrug-resistant pathogens. We aimed to improve compliance with these guidelines and assess outcomes. METHODS: We implemented a performance-improvement initiative in four academic medical centres in the USA with protocol-based education and prospective observation of outcomes. @entity1 were assessed for severity of illness and followed up until @entity204 , hospital discharge, or day 28. We included @entity1 in intensive-care units who were at risk for multidrug-resistant @entity55 and were treated empirically. FINDINGS: 303 @entity1 at risk for multidrug-resistant @entity55 were treated empirically, and prescribed treatment was guideline compliant in 129 @entity1 and non-compliant in 174 @entity1 . 44 (34%) @entity1 died before 28 days in the compliance group and 35 (20%) died in the non-compliance group. Five @entity1 in the compliance group and seven in the non-compliance group were lost to follow-up after day 14. Kaplan-Meier estimated survival to 28 days was 65% in the compliance group and 79% in the non-compliance group (p=0  0042). This difference persisted after adjustment for severity of illness. Median length of stay and duration of mechanical ventilation did not differ between groups. Compliance failures included non-use of dual treatment for Gram-negative pathogens in 154 @entity1 and absence of @entity3256 -resistant @entity794 coverage in 24 @entity1 . For @entity1 in whom pathogens were subsequently identified, empirical treatment was active in 79 (81%) of 97 of @entity1 receiving compliant therapy compared with 109 (85%) of 128 of @entity1 receiving non-compliant therapy. INTERPRETATION: Because adherence with empirical treatment was associated with increased mortality, we recommend a randomised trial be done before further implementation of these guidelines. FUNDING: Pfizer, US Medical.
