A total of 50 patient charts were reviewed. The mean patient age was 77 years (median 78 years; range 36 to 95 years), and 46% of the patients were women (Table 1). Forty-three (86%) of the patients had been treated on a ward and the remainder of the patients, in critical care units. The majority of patients had more than one comorbid condition, with cardiac disease pre­dominating (37 [74%] of the patients). Twenty-four (48%) of the patients had a history of antibiotic use within 3 months before the diagnosis of HAP. The antimicrobial agents most commonly administered within 3 months preceding diagnosis of HAP were 6-lactams (20/24 or 83%), fluoroquinolones (14/24 or 58%), and agents active against oral and gut anaerobic organisms (13/24 or 54%).

On average, HAP was diagnosed on the eighth day of admission (median 6 days, range 1 to 29 days). Late-onset HAP, defined as occurring 5 or more days after hospital admission, was observed in 34 (68%) of the patients.
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Table 1. Characteristics of 50 Patients with Hospital- Acquired Pneumonia


Characteristic


No. (and
%)*


Aget


77 (13, 78, 36-95)


Sex (no. and
% of
women)


23 (46)


Floor


Ward


43


(86)


Critical care units


7


(14)


Past medical history


Cardiac


37


(74)


Malignancy


16


(32)


Musculoskeletal


14


(28)


Respiratory


13


(26)


Endocrine


12


(24)


Gastrointestinal


11


(22)


Psychiatric


11


(22)


Neurologic


9


(18)


Renal


4


(8)


Dermatologic


2


(4)


Other


9


(18)


Reason for admission


Cardiac


10


(20)


Surged


10


(20)


Malignancy


8


(16)


Stroke


7


(14)


Fracture


3


(6)


Gastrointestinal


2


(4)


Infection


2


(4)


Chronic lung disease


1


(2)


Trauma


1


(2)


Other


6


(12)


Antibiotics used recently§


24


(48)


B-Lactams


20


(83)


Fluoroquinolones


14


(58)


Agents with anaerobic coverage!!


13


(54)


Aminoglycosides


4


(17)


Vancomycin


1


(4)


Sulfonamides


1


(4)


Other


1


(4)

The diagnosis of HAP was based on clinical, laboratory, and radiologic evidence in 19 (38%) cases. Sputum was obtained for culture from 19 patients, and the result was positive for 14 patients (74%) (for some of whom more than one organism was isolated). For most patients, the organisms isolated were gram- negative bacilli, including Hemophilus influenzae (4 patients), Serratia marcescens (3), Klebsiella spp. (2), Pseudomonas spp. (2), Acinetobacter spp. (1), Escherichia coli (1), Moraxella catarrhalis (1), and Morganella morganii (1). MSSA (a gram-positive organism) was isolated from 3 samples.
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Table 2. Initial Selection of Antimicrobials for the Management of Hospital-Acquired Pneumonia


Regimen No.
(%) of
patients


Initial antimicrobial selection
(n



= 50)


Empiric


41


(82)


Culture-directed


9 (18)


Empiric regimen selected
(n



= 41)



Monotherapy


Fluoroquinolones


17


(41)


Levofloxacin


15


(37)


Ciprofloxacin


2


(5)


Cephalosporins


13


(32)


Ceftriaxone


10


(24)


Cefuroxime


2


(5)


Ceftazidime


1


(2)


Macrolides


2


(5)


Other


2


(5)



Combination therapy


1




(2)


Fluoroquinolone
+ B-lactam
or


2


(5)


anti-anaerobic agent


Second- or third-generation cephalosporin


5


(12)


+
macrolide or anti-anaerobic agent


Culture-directed regimen selected
(n



= 9)


Ciprofloxacin


5 (56)


Cefazolin
+
fluoroquinolone or
aminoglycoside


4 (44)

Blood was taken for culture from 41 patients, and the result was positive for 7 (17%) of these patients. The following organisms were isolated from blood: MSSA (3 patients), Klebsiella spp. (2), Bacteroides fragilis (1), Enterococcus faecalis (1), Proteus mirabilis (1), and Serratia marcescens (1). There was no concordance between sputum cultures and blood cultures, which indicates that the positive blood culture results might have reflected concurrent infections.

The initial choice of antimicrobial regimen was selected empirically for 41 patients (82%) (Table 2).

Levofloxacin was the most commonly chosen single agent (15/41 or 37%) for initial empiric therapy. All patients who received levofloxacin empirically were situated in a ward setting rather than a critical care setting. Ceftriaxone was also chosen frequently as empiric therapy (10/41 or 24%). Other empiric choices included first- and second-generation cephalosporins, macrolides, fluoroquinolones, vancomycin, and combination therapy with agents that are active against anaerobic organisms (i.e., clindamycin or metronidazole). In patients whose therapy was directed by the culture results, the most commonly chosen agent was ciprofloxacin (5/9 or 56%).
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Table 3. Characteristics of Antibiotic Therapy


Characteristic of Therapy


No. (%)
of patients*


Changed during hospital stay
(n



= 50)


Yes


37


(74)


No


13


(26)


Rationale for changes in therapy
(n



= 37)


PO step-down


10


(27)


Culture and sensitivity results


6


(16)


Suspected aspiration


6


(16)


Clinical improvement


3

(8)


Concurrent infection


2


(5)


Renal dose adjustment


2


(5)


Clinical worsening

1


(3)


Hypersensitivity

1


(3)


Unknown


6


(16)


Length of treatment (days)t


In hospital


8


(5.7, 7, 1-27)


Total


10


(6.2, 8, 1-27)


Length of hospital stayt


24


(23.9, 17, 4-129)


PO =
by mouth.


*Unless indicated otherwise.


tMean (standard deviation, median, range).

On average, the duration of hospital stay was 24 days (range 4 to 129 days). Patients were treated with antimicrobial agents for HAP for an average of 8 days in hospital. Thirty-seven (74%) patients had a change in their antimicrobial regimen during their hospital admission (Table 3). The most common reason for an alteration in therapy was oral step-down of the antimicrobial agents (10/37 or 27%).
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Table 4. Outcomes for 50 Patients Treated for Hospital-Acquired Pneumonia


Outcome


No. (%)
of patients


Time to defervescence


Afebrile throughout


27 (54)


<3 days


16 (32)


4-7 days


5 (10)


>7 days


2 (4)


Clinical outcome


Cure


34 (68)


Death


16 (32)

Twenty-seven patients (54%) were afebrile through­out the course of the infection (Table 4). In the remaining patients, time to defervescence ranged from 1 to 18 days once antibiotic therapy was initiated. A cure of the pneumonia was achieved in 34 patients (68%).