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Abstract

Introduction: Nationally, 93% of patients with community-acquired pneumonia (CAP) receive guideline-concordant therapy. Severe CAP, defined as CAP treated in the ICU, accounts for up to 35% of CAP. Early initiation of antibiotic treatment is extremely important for these patients, but the proportion of patients that receive guideline-concordant therapy is unknown. Hypothesis: Not all patients with severe CAP receive guideline-concordant care. Methods: Using a large national database, we included patients who were discharged between 7/07-6/10; had a principal diagnosis of pneumonia or a principal diagnosis of sepsis or respiratory failure combined with a secondary diagnosis of pneumonia; and, by the second hospital day, had been admitted to the ICU, undergone a chest radiograph, and were treated with antibiotics. We excluded patients with health care-associated pneumonia and those in whom pneumonia was not present on admission. Initial treatment regimens were defined as guideline-concordant if, during the first two days of hospitalization, the patient received coverage for typical and atypical CAP pathogens. Results: 20,704 patients at 346 hospitals met inclusion criteria. Inpatient mortality was 14.1%. Mechanical ventilation was initiated by day 2 in 8,069 (39%) and on day 3 or later in 1,385 (7%). Most patients (85%) were initially treated with guideline-concordant therapy. Among 17,639 patients who received guideline-concordant regimens, 4028 (23%) received coverage for typical and atypical CAP organisms but not Methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas; 1,080 (6%) received additional coverage for MRSA; 6,219 (35%) received coverage for Pseudomonas; and 6,312 (36%) received coverage for both MRSA and Pseudomonas. Among 3,065 patients who initially received guideline-discordant therapy, most (2,925, 95%) received no coverage for atypical organisms. Conclusions: There is variation in initial antibiotic choice for severe CAP. Although most patients received guideline-concordant regimens, about 15% received no initial coverage for atypical organisms.