HCAP guidelines, CPR survival, and more

Summaries from ACP Hospitalist Weekly.

HCAP prescribing guidelines were not usually followed and didn't change outcomes

Guidelines on which antibiotics to prescribe for health care-associated pneumonia (HCAP) gradually changed practice but did not appear to affect mortality or length of stay, a recent study found.

The retrospective cohort study included 488 hospitals that had reported data to the Premier database between July 2007 and November 2011. Researchers identified 149,963 patients who met criteria for HCAP according to 2005 guidelines from the American Thoracic Society and Infectious Diseases Society of America and assessed whether their treatment was fully, partially, or not concordant with the guidelines.

A fully concordant regimen included an antipseudomonal cephalosporin or carbapenem or a beta-lactam/lactamase inhibitor, plus an antipseudomonal quinolone or aminoglycoside, plus an antibiotic with activity against methicillin-resistant Staphylococcus aureus (MRSA), such as vancomycin or linezolid. Partially concordant was defined as one recommended antibiotic for Pseudomonas species plus one for MRSA by the second day of hospitalization. Results were published in the November 2017 Journal of Hospital Medicine.

Overall, 19.6% of the patients received fully concordant antibiotics, 21.7% received partially concordant care, and 58.9% received discordant care. Of the patients who received discordant prescriptions, 81.5% were treated according to guidelines for community-acquired pneumonia. Concordance with guidelines varied by hospital and increased over time, by 2.2% per six-month interval on average. The increase in guideline-concordant care was not associated with any change in hospital rates of mortality, excess length of stay, or progression to respiratory failure.

The HCAP guidelines were always controversial, and a recent update removed the specific recommendations for HCAP and placed HCAP into the guidelines for CAP instead, the study authors noted. A concern with the guidelines was that the criteria for HCAP did not accurately predict which patients had multidrug-resistant organisms (MDROs). This concern is supported by the lack of change in outcomes observed in this study, the authors said, and it may be one explanation for the low rate of fully concordant care, although the increase in concordance over time suggests that the best explanation might be physicians' lack of familiarity with the guidelines.

“Ironically, as consensus was building that HCAP is a poor marker for MDROs, routine empiric treatment with vancomycin and piperacillin-tazobactam ... have become routine in many hospitals,” the study authors wrote. They called for additional studies to see if this trend in prescribing has stabilized or reversed.

Score predicts risk of cardiovascular death in patients who survive CPR

A recently developed score may help predict outcomes for patients who were successfully resuscitated after out-of-hospital cardiac arrest for reasons other than ST-elevation myocardial infarction (STEMI).

Photo by Thinkstock
Photo by Thinkstock.

Researchers developed and validated their prediction score using data from 44 U.S. and European hospitals in the International Cardiac Arrest Registry (INTCAR). Included patients (638 in the derivation cohort and 318 in the validation cohort) all had successful resuscitation after cardiac arrest without STEMI and survived to ICU admission. They were classified into two outcomes groups: 1) circulatory-etiology death or 2) neurological-etiology death or survival.

The study found five predictors of circulatory-etiology death that the researchers made into a score: pre-existing Coronary artery disease (derivation cohort odds ratio [OR], 2.86), nonshockable Rhythm (OR, 1.75), initial Ejection fraction below 30% (OR, 2.11), Shock at presentation (OR, 2.27), and ischemic Time above 25 minutes (OR, 1.42). A higher CREST score was associated with significantly higher rates of circulatory-etiology death: Patients with zero or one point had only a 10% to 11% risk compared to 50% in those with all five points. The results were published online by Circulation on Oct. 26, 2017, and appeared in the January 16, 2018, issue.

The study authors concluded that the tool could improve triage of cardiac arrest survivors without STEMI. “Such a tool may be especially useful at the bedside, ideally in conjunction with an assessment of the severity of brain injury,” the study authors said, noting that all of the components are obtainable at the time of ICU admission and that the score is easy for clinicians to calculate. “Our results suggest the CREST tool could be a more objective measure to assist in the early assignment of patients to appropriate therapies and interventions, or away from potentially harmful or futile interventions,” they wrote.

The authors did caution that the score requires prospective validation in the ED and that the INTCAR definition of shock (hypotension despite vasopressors) differs from current American College of Cardiology terminology. They also suggested the score eventually be combined with a neurological risk stratification tool.

Making readmission penalties hospital-wide could hurt safety-net facilities more than others

Expanding the Hospital Readmissions Reduction Program (HRRP) to include all admissions instead of targeting specific conditions would increase penalties, especially for safety-net hospitals, an analysis found.

Researchers used Medicare claims from 2011 to 2013 to estimate the effects of changing from the existing condition-specific readmission measures to a hospital-wide measure. Their sample included more than 4 million condition-specific admissions and more than 6 million admissions for the hospital-wide measure. The patients were treated at 3,443 hospitals, 688 of them considered safety-net hospitals. Results were published in the Oct. 19, 2017, New England Journal of Medicine.

Under the theoretical hospital-wide measure, based on a year of data (instead of the HRRP's current three years), the study found that 76 more hospitals would be eligible for participation in the penalty program, which requires at least 25 relevant admissions per hospital. Across all hospitals, penalties would increase from 0.42% of Medicare base diagnosis-related group payments to 0.89%. The disparity in penalties between safety-net hospitals and other hospitals would also increase, from −0.03 (±0.02) percentage point to 0.41 (±0.06) percentage point.

“Policymakers have shown substantial interest in moving to a hospital-wide measure of readmissions for the HRRP. We found that such a change could address some concerns about the HRRP but exacerbate others,” the authors wrote. They noted that increase in the number of hospitals that could participate in the program was modest and that the increase in total penalties identified by the study could be adjusted to restore budget neutrality.

However, it would be more difficult to address the increase in disparities between safety-net and other hospitals, the authors said. One strategy would be to stratify hospitals by either the proportion of patients on Medicaid or eligible for Medicaid and Medicare, but that could allow some hospitals with high readmission rates to avoid penalties and give them less incentive to reduce readmission.

Other potential issues include that while now hospitals can get or avoid penalties on any of five measures, they would have only one chance to be penalized or not based on their overall readmissions, concentrating the penalties on a smaller group of facilities. “We cannot know whether such a change would improve the actual quality of care or produce unintended consequences,” the authors concluded.

Sputum culture may help guide antibiotic treatment in patients with hospital-acquired pneumonia

Noninvasive sputum culture may be helpful in guiding treatment for patients with hospital-acquired pneumonia (HAP), a recent study found.

HAP guidelines from the Infectious Diseases Society of America include a weak recommendation for using noninvasive sputum culture rather than empiric treatment to guide care. Realizing that data on the practice are limited, researchers retrospectively assessed the yield of sputum culture in adults with HAP admitted from January 2007 to July 2013 to an academic medical center.

Results were published online on Oct. 18, 2017, by the Journal of Hospital Medicine and appeared in the January 2018 issue.

The cohort had 1,172 hospitalizations with a diagnosis of non-ventilator-associated HAP. In 344 of these hospitalizations (29.4%), one or more sputum specimens were collected and cultured after day two of admission and within seven days of HAP diagnosis. Of a total of 478 sputum specimens, 63 (13.2%) were positive, 109 (22.8%) were negative, and 306 (64.0%) were contaminated.

Significant predictors of a positive culture were chronic lung disease (relative risk, 2.0; 95% CI, 1.2 to 3.4) and steroid use (relative risk, 1.8; 95% CI, 1.1 to 3.2). The three most common organisms were gram-negative rods not further speciated (25.9%), Staphylococcus aureus (21.0%), and Pseudomonas aeruginosa (14.8%).

The authors noted limitations of the study, such as its single-center, retrospective design and the possibility of selection bias due to differences between patients with HAP who had sputum collected and those who did not. They added that they did not examine outcomes among patients treated based on culture results versus those treated empirically.

“Because of the relative ease of obtaining a sputum sample and the microbiologic distribution in our study (representing a mix of commonly drug-resistant pathogens and more typical community-acquired pathogens), we suggest that sputum culture in HAP is a useful diagnostic tool with the potential to inform antibiotic escalation or de-escalation,” the authors wrote.

Major bleeding, mortality risks after VTE similar on DOACs or warfarin

Direct oral anticoagulants (DOACs) and warfarin carried similar risks of death and major bleeding in the first 90 days of venous thromboembolism (VTE) treatment, a recent multicenter study found.

Researchers used U.S. and Canadian databases to retrospectively assess 59,525 adults who, between Jan. 1, 2009, and March 31, 2016, had incident VTE and a prescription for a DOAC or warfarin within 30 days of diagnosis. The propensity-matched cohort consisted of 12,489 DOAC users and 47,036 warfarin users. Primary outcomes were hospital admission or ED visit for major bleeding and all-cause mortality within 90 days of treatment. Results were published online on Oct. 17, 2017, by The BMJ.

Photo by Thinkstock
Photo by Thinkstock.

Overall, 1,967 (3.3%) patients had a major bleeding event, and 1,029 (1.7%) died over a mean follow-up of 85.2 days. The risk of major bleeding was similar for patients taking DOACs compared to those taking warfarin (pooled hazard ratio, 0.92; 95% CI, 0.82 to 1.03). The risk of death was also similar between DOAC and warfarin users (pooled hazard ratio, 0.99; 95% CI, 0.84 to 1.16).

Overall results for both outcomes were similar irrespective of chronic kidney disease status, age, and sex. Results also remained unchanged after 180 days of follow-up.

The authors noted limitations of the study, such as its observational nature and the possibility of unmeasured confounders. They noted that the safety of DOAC treatment of VTE beyond 180 days remains uncertain, adding that 95% of DOAC users in the study were taking rivaroxaban, so further study of other DOAC agents is needed.

... [G]iven the absence of an increased bleeding risk and the advantages associated with its use particularly around frequency of monitoring and dosing, our results suggest that DOACs may be considered as a treatment option for patients with venous thromboembolism who are candidates for anticoagulation,” they wrote.