Impact of Empirical Treatment Recommendations From 2017 European Guidelines for Nosocomial Pneumonia

Abstract

Background: The management of nosocomial pneumonia represents a major challenge in the ICU. European guidelines from 2017 proposed an algorithm for the prescription of empirical antimicrobial treatment based on medical history, local ecology, and severity (ie, presence or absence of septic shock). We assessed this algorithm's usefulness by comparing outcomes with and without guideline adherence in a population at high risk of multiresistance and mortality.

Research question: Are the recommendations of the latest European guidelines effective in reducing the incidence of adverse outcomes in patients with nosocomial pneumonia admitted to the ICU?

Study design and methods: We retrospectively analyzed data from a prospective cohort of 507 patients from 6 ICUs in our center. To minimize bias, we only included patients with microbiologically confirmed pneumonia. The primary outcome was 28-day mortality. Secondary outcomes were 90-day mortality, ICU mortality, inadequate treatment, treatment failure, and overtreatment.

Results: In total, 315 patients met the inclusion criteria. Outcomes were comparable in the groups with and without guideline adherence, except for overtreatment, which was higher when guidelines were followed (42.5% vs 66.3%; P < .001). In the subgroup without septic shock treated according to guidelines, reductions were noted in both ICU mortality (28.8% vs 14.5%; P = .031) and adjusted 28-day mortality (hazard ratio, 3.07; 95% CI, 1.13-7.85; P = .027). By contrast, no benefit was observed when patients presented with septic shock at diagnosis.

Interpretation: Our findings indicate that the European guideline treatment algorithm is effective in reducing mortality in patients without septic shock but not in those with septic shock at the time of diagnosis. Future studies should clarify whether adjustments need to be made to improve outcomes in patients with septic shock.

Keywords: antimicrobial treatment; hospital-acquired pneumonia; intensive care medicine; nosocomial infection; septic shock; ventilator-associated pneumonia.