Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

Does de-escalation of antimicrobials lead to better outcomes for persons with VAP and potentially with HCAP or HAP? (or at least better utilization of antimicrobials?)

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

1. De-escalation strategies vs. non-de-escalation strategies
2. De-escalation in patients with cultures obtained vs. those with no cultures obtained

• De-escalation in patients with positive cultures vs. negative cultures.

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

1. Immunocompetent adults with a clinically defined VAP, HCAP or HCAP and either positive or negative cultures.
2. Immunocompetent adults with clinically defined VAP, HCAP or HAP with cultures obtained vs. those with no cultures obtained

• For those with cultures, positive vs. negative cultures.

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Immunocompetent adults treated in the intensive care unit with VAP or HAP.

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

Frequency of de-escalation Reduction of antibiotic use Reduction in modification of initial therapy

Microbiologic eradication Time to microbiologic eradication/resolution of pneumonia Reduction in duration of therapy Reduction in length of stay Reduction in time of mechanical ventilation Reduction in attributable mortality Prevention of the emergence of drug resistance while in the hospital

Describe any health-related risks, side effects, or harms that you are concerned about.

Death Drug resistance Clinical failure Extended hospitalization

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Infectious diseases, including HIV/AIDS

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Children
• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare

Importance

Describe why this topic is important.

Hospital-acquired pneumonia (HAP), including ventilator-associated pneumonia (VAP), and healthcare-associated pneumonia (HCAP) are important causes of morbidity, mortality and longer hospital stays. In immunocompetent adults VAP, HAP and HCAP are caused primarily by one or more bacterial pathogens. The main focus of this topic is on immunocompetent adults with VAP, followed by HCAP and then HAP, because the latter two rarely have microbiologic data.

Prompt, initial, empiric antibiotic therapy is recommended for all patients suspected of having VAP.

These patients are also at risk for multidrug-resistant (MDR) bacterial pathogens, especially in the intensive care unit (ICU) and transplant recipients, which can delay appropriate therapy. Use of an ICU-specific, broad-spectrum empiric regimen may reduce the incidence of inappropriate initial therapy in the ICU setting, but ultimately, the empiric strategy will lead to many patients receiving an initial broad-spectrum therapy.

Excessive antibiotic use is also a major contributor to increased drug resistance. In an effort to limit the emergence of drug resistance in the hospital/healthcare setting, ATS/IDSA guidelines (2005) recommend a de-escalation of antibiotics, i.e. narrowing initial therapy to the most focused regimen possible on the basis of clinical and microbiologic data. This recommendation is supported by moderate level evidence 8. Describe why this topic is important.

Hospital-acquired pneumonia (HAP), including ventilator-associated pneumonia (VAP), and healthcare-associated pneumonia (HCAP) are important causes of morbidity, mortality and longer hospital stays. In immunocompetent adults VAP, HAP and HCAP are caused primarily by one or more bacterial pathogens. The main focus of this topic is on immunocompetent adults with VAP, followed by HCAP and then HAP, because the latter two rarely have microbiologic data.

Prompt, initial, empiric antibiotic therapy is recommended for all pati

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

This topic was given a high priority by a multi-disciplinary stakeholder panel (including patient and employer perspectives) convened to identify and select important research questions on RTIs amenable for systematic review.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

The stakeholder panel noted the uncertainty in the evidence of effectiveness of a de-escalation strategy and the variation in its use in hospitalized persons with nosocomial pneumonia.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

A report would inform clinical decision-making for patients, payers and providers.

Describe the timeframe in which an answer to your question is needed.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Individuals such as women, children, the elderly, and individuals with special health care needs, including the disabled and those needing chronic care, would be at higher risk for hospital/healthcare-associated pneumonia and antibiotic exposure, as these populations frequent healthcare facilities more often for treatment for other conditions.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

A report would inform clinical decision-making for patients, payers and providers.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

The Blue Cross and Blue Shield Association Technology Evaluation Center is an Evidence-based Practice Center of AHRQ.