VAP Rates Unchanged

In a research letter to JAMA Metersky and colleagues (1) report that ventilator-associated pneumonia (VAP) rates have remained near 10% since 2005. The authors reviewed Medicare Patient Safety Monitoring System (MPSMS) data on a representative sample of more than 86,000 critically ill patients treated at 1330 US hospitals between 2005 and 2013. To meet a diagnosis of VAP patients were required to have at least 2 days' ventilation in intensive care units; a chest radiograph with a new finding suggesting pneumonia; a physician diagnosis of pneumonia; and an order for antibiotics. VAP incidence was 10.8% (95% confidence interval, 7.4% - 14.4%) during 2005 to 2006 and 9.7% (95% confidence interval, 5.1% - 14.9%) during 2012 to 2013.

In contrast, data from the CDC's National Healthcare Safety Network (NHSN) have shown declines in VAP rates of 71% and 62% in medical and surgical intensive care units, respectively, between 2006 and 2012 (2,3). "The most likely explanation for the discrepancy is thought to be bias in reporting to CDC by the hospitals," Dr. Metersky told Medscape Medical News (4). Dr. Charles S. Dela Cruz at Yale agrees. "Strict and varying VAP measure definitions and the hospital reporting mechanisms possibly contributed to the differences in rates," he said.

VAP has no standard definition and its diagnosis has considerable clinical variability. Other than removing the endotracheal tube as quickly as possible, VAP prevention guidelines are non- or weakly evidence-based (5). Furthermore, financial incentives from CMS for low VAP rates may have contributed to the bias in reporting (6).

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Metersky ML, Wang Y, Klompas M, Eckenrode S, Bakullari A, Eldridge N. Trend in ventilator-associated pneumonia rates between 2005 and 2013. JAMA. 2016 Nov 11. [Epub ahead of print] [CrossRef] [PubMed]
2. Edwards JR, Peterson KD, Andrus ML, et al; NHSN Facilities. National Healthcare Safety Network (NHSN) Report, data summary for 2006, issued June 2007. Am J Infect Control. 2007;35(5):290-301. [CrossRef] [PubMed]
3. Dudeck MA, Weiner LM, Allen-Bridson K, et al. National Healthcare Safety Network (NHSN) report, data summary for 2012, device-associated module. Am J Infect Control. 2013;41(12):1148-66. [CrossRef] [PubMed]
4. Swift D. No drop in VAP rates, study contends. Medscape Medical News. November 21, 2016. Available at: http://www.medscape.com/viewarticle/872157?nlid=110853_3464&src=WNL_mdplsfeat_161129_mscpedit_ccmd&uac=9273DT&spon=32&impID=1243721&faf=1 (accessed 12/2/16).
5. Padrnos L, Bui T, Pattee JJ, Whitmore EJ, Iqbal M, Lee S, Singarajah CU, Robbins RA. Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines. Southwest J Pulm Crit Care 2011;3:40-8.
6. Cassidy A. Medicare's hospital-acquired condition reduction program. Health Affairs. August 6, 2015. Available at: http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=142  (accessed 12/2/16).

Cite as: Robbins RA. VAP rates unchanged. Southwest J Pulm Crit Care. 2016;13(6):288-9. doi: https://doi.org/10.13175/swjpcc134-16 PDF

IDSA Releases Updated Coccidioidomycosis Guidelines

The Infectious Diseases Society of America (IDSA) has released updated Guidelines for the Treatment of Coccidioidomycosis, also known as cocci or Valley Fever (1). Coccidioidomycosis is a fungal infection endemic to the southwestern United States and a common cause of pneumonia and pulmonary nodules in this area. However, the infection can disseminate systemically especially in immunocompromised hosts and certain ethnic populations resulting in a variety of pulmonary and extrapulmonary complications. In addition to recommendations for these complications, the new guidelines address management of special at-risk populations, preemptive management strategies in at-risk populations and after unintentional laboratory exposure. The guidelines also suggest shorter courses of antibiotics for hospitalized patients and more ambulatory treatment for most individuals who have contracted Valley Fever.

The panel was led by John N. Galgiani, MD, director of the Valley Fever Center for Excellence at the University of Arizona Health Sciences. Galgiani led a panel of 16 experts including faculty from the University of Arizona, Mayo Clinic Arizona, University of California San Diego, University of California Los Angeles, Utah, Barrows Neurological Institute and the University of Utah.  

A reference booklet, “Valley Fever (Coccidioidomycosis)—Tutorial for Primary Care Physicians,” from the UA Valley Fever Center for Excellence complements the guidelines and is available through the Southwest Journal of Pulmonary and Critical Care (2) and also available at the Valley Fever Center for Excellence website.

The guidelines begin with a disclaimer that it is "important to realize that guidelines cannot always account for individual variation among patients and ... not intended to supplant physician judgment". This is especially important because many of the guidelines are based on expert  opinion rather than strong scientific evidence.

References

1. Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Geertsma F, Hoover SE, Johnson RH, Kusne S, Lisse J, MacDonald JD, Meyerson SL, Raksin PB, Siever J, Stevens DA, Sunenshine R, Theodore N. 2016 Infectious Diseases Society of America (IDSA) clinical practice guideline for the treatment of coccidioidomycosis. Clin Infect Dis. 2016 Sep 15;63(6):e112-46. [CrossRef] [PubMed]
2. Galgiani JN. Valley fever (coccidioidomycosis): tutorial for primary care physicians. Southwest J Pulm Crit Care. 2015;10(5):265-88. [CrossRef]

Cite as: Robbins RA. IDSA releases updated coccidioidomycosis guidelines. Southwest J Pulm Crit Care. 2016;13(3):125. doi: http://dx.doi.org/10.13175/swjpcc090-16 PDF