In a well-intentioned performance improvement initiative, Daniel Kett and the IMPACT-HAP team prospectively observed 303 patients at risk for MDR pneumonia at four academic hospitals. Surprisingly, more of those who got appropriate antibiotics died (34%) than those treated off-ATS/IDSA guidelines (20%), with Kaplan-Meier-modeled 28-day survival of 65% vs. 79%, p=0.0044. The authors were concerned enough to recommend against continued adherence to ATS/IDSA HCAP antibiotic guidelines, pending a randomized trial. The study was funded by Pfizer, who have been reported to be getting out of the antibiotics business. Lancet Infect Dis 2011;11:181-189.
Donald Craven and Michael Niederman, authors of the ATS/IDSA guideline, didn't care much for this article. Read what they had to say to us about it.
This controversial topic and paper generated multiple other responses worth reading; all are free full text:
Pavlos Myrianthefs, Konstantinos Ioannidis et al (They generally agreed with Kett.)
Patrick Bradley (hypothesizes that some cases of VAP are actually ARDS, which of course is not antibiotic-responsive)