Practice patterns for antibiotic de-escalation in culture-negative healthcare-associated pneumonia.

BACKGROUND: Published guidelines for the treatment of healthcare-associated pneumonia (HCAP) recommend initial broad-spectrum antibiotics with appropriate de-escalation based on culture results. Guideline recommendations are based on data from intubated patients, in whom cultures are easily obtained. The approach to antibiotic de-escalation for culture-negative patients has not been addressed. Consequently, there are no published reports that describe the current standard of practice. PATIENTS AND METHODS: All patients admitted to a university hospital with a diagnosis of HCAP, as defined by use of a pneumonia orderset, were identified retrospectively over a 2-year period. Antibiotics prescribed on admission, during hospital stay, and on discharge were recorded. De-escalation was defined as a change in the initial antibiotic therapy from broad- to narrow-spectrum coverage within 14 days of the initial prescription. The Pneumonia Severity Index was used for risk-adjustment. RESULTS: A total of 102 patients were included in the analysis; of these, 72% (n = 73) were culture-negative. There were more males in the culture-negative than culture-positive group; otherwise, baseline characteristics were similar. Antibiotic therapy was de-escalated in 75% of the culture-negative group and 77% of the culture-positive group (p = 1.00). Culture-negative patients were de-escalated approximately 1 day earlier than culture-positive patients (3.93 vs. 5.04 days, p = 0.03). Culture-negative patients who were de-escalated had a shorter length of hospitalization, lower hospital costs, and lower mortality rates. In 70% of the culture-negative patients, a respiratory fluoroquinolone was chosen for de-escalation. CONCLUSION: In this single-center study, most of the patients with culture-negative HCAP were safely de-escalated to a respiratory fluoroquinolone.

Cost-effectiveness evaluation of measles immunization strategies on a college campus.

Since live rubeola vaccine became available in 1963, routine immunization of children at age 15 months has been the recommended strategy for eliminating measles in the United States. However, due to increasing measles outbreaks, especially among previously immunized populations, the Immunization Practices Advisory Committee (ACIP) recently recommended modifying the one-dose measles vaccination policy to a two-dose schedule, one at 15 months and one at age 5 or 6 years. To address the present college population, ACIP recommended vaccinating all college students who lack proof of immunity. We used the methods of decision analysis to examine the cost effectiveness of implementing such a program in a specific college population, namely, students at the University of California at Los Angeles (UCLA). We developed a model to examine three possible vaccination strategies: "wait," "screen," and "vaccinate all." Estimates of probabilities and cost were derived from several outbreaks at UCLA as well as statewide data. In the baseline case, the least expensive strategy is to wait until an outbreak occurs before implementing a vaccination program. The additional cost incurred by screening per measles case avoided is $122,871. However, using sensitivity analysis, we found that the overall cost of elective vaccination strategies is driven by the cost of the vaccine itself. If vaccine could be provided at a nominal cost to the university, a strategy of vaccinating all students without proof of immunity (by either history of two vaccinations or positive titer) would provide the high level of immunity needed to prevent outbreaks and still be most cost effective ($16,644 per measles case avoided).