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Adherence to the American Thoracic Society (ATS) guidelines for the empiric antibiotic treatment of admitted adults with hospital-acquired, ventilator-associated and healthcare-associated pneumonia (HAP/ VAP/ HCAP) from Cardinal Santos Medical Center.


Eunis Crystia G. Suzara,
Emily Bomasang

Related Institution

Publication Information

Publication Type
Publication Sub Type
Journal Article, Original
Philippine Journal of Internal Medicine
Six times a year (6x/year)
Publication Date
July-August 2007
171 - 178


OBJECTIVES: Hospital acquired pneumonia is one of the most common nosocomial infection in the Philippines, ranking 3rd in one local study and continues to be a major health problem in our setting. This causes excess morbidity, mortality, personal distress, length and cost of hospitalization. In 2004, the American Thoracic Society released a guideline for the management of patients with pneumonia. The aims of our study are: 1.) to determine the prevailing practices of physicians at Cardinal Santos Medical Center (CSMC) with regard to empiric antibiotic therapy of patients with HAP/VAP/HCAP, and 2.) to compare the outcomes of patients who have been managed in accordance to the ATS guidelines with those managed differently.

METHODS: This was a descriptive study that included all adult patients admitted at CSMC from January to April 2006 who were suspected to have developed nosocomial pneumonia during their hospital admission. All patient charts were reviewed and were categorized based on the time of onset of pneumonia and the presence of risk factors for development of multidrug resistant (MDR) pathogens. The Clinical Pulmonary Infection Score (CPIS) was used to ascertain the presence of pneumonia (CPIS > 6). Actual empiric antibiotic treatment given for each category was compared to the recommendation set by the ATS guideline for the management of HAP/VAP/HCAP. The outcomes measured were resolution or non-resolution of pneumonia after 3 days of the empiric therapy and mortality (secondary to HAP or to other causes) and were analyzed based on the adherence to the ATS guideline. We also obtained the isolates of the sputum or tracheal aspirate cultures and sensitivity and resistance patterns were noted.

RESULTS: Forty-four patients of the 1,998 admissions in the four-month study developed HAP/VAP/HCAP. There were 13 patients who developed recurrent pneumonia and a total of 62 episodes of hospital-acquired pneumonia were analyzed for this study. The cumulative incidence for nosocomial pneumonia was 3.2 percent, with most cases occurring in the ICO. Most cases (39 episodes, 62.9 percent) were given empiric treatment consistent with the recommendation of the ATS guideline. The most commonly used empiric therapy for early-onset pneumonia with no risk factors for MDR organisms were quinolones or a combination regimen of two anti-pseudomonal antibiotic (usual combination includes a fluoroquinolone) for patients with late onset pneumonia. This study showed resolution of pneumonia in those cases that were given empiric therapy that was consistent with the ATS guideline (74.4 percent vs 34.8 percent among non-adherent empiric therapy) with lower mortality attributable to HAP compared to cases with non-adherence (5.1 percent vs 30.4 percent). However, there was no statistically significant difference between the two groups (p value=0.20) in terms of the overall outcome. The foremost microbiological isolate was Pseudomonas aeruginosa (31.6 percent). The gram-negative bacteria isolated were least resistant to amikacin, piperacillin-tazobactam and imipenem-resistance rates: 4.8 percent, 13.2 percent and 17.2 percent- respectively, with high level of resistance to ampicillin, ceftazidime and ciprofloxacin (92.3 percent, 72.1 percent and 50.7 percent resistance rates respectively).

CONCLUSION: This study showed that more than 50 percent of HAP/VAP/HCAP cases in our institution were managed according to the recommendations given by the ATS guidelines for the empiric antibiotic therapy. There was a non-significant trend towards benefit in terms of resolution of pneumonia and mortality attributable to pneumonia in the group given empiric treatment based on the ATS guideline. The incidence of nosocomial pneumonia among adult patients admitted at CSMC was low. Predominance of gram-negative bacterial isolates was seen in this study, with increased resistance of the pathogens to ampicillin, ceftazidime and ciprofloxacin.


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