Abstract
Background
Pneumonia remains a significant global health concern, particularly among those requiring admission to the intensive care unit (ICU). Despite the availability of international guidelines, there remains heterogeneity in clinical management. The D-PRISM study aimed to develop a global overview of how pneumonias (i.e., community-acquired (CAP), hospital-acquired (HAP), and Ventilator-associated pneumonia (VAP)) are diagnosed and treated in the ICU and compare differences in clinical practice worldwide.
Methods
The D-PRISM study was a multinational, survey-based investigation to assess the diagnosis and treatment of pneumonia in the ICU. A self-administered online questionnaire was distributed to intensive care clinicians from 72 countries between September to November 2022. The questionnaire included sections on professional profiles, current clinical practice in diagnosing and managing CAP, HAP, and VAP, and the availability of microbiology diagnostic tests. Multivariable analysis using multiple regression analysis was used to assess the relationship between reported antibiotic duration and organisational variables collected in the study.
Results
A total of 1296 valid responses were collected from ICU clinicians, spread between low-and-middle income (LMIC) and high-income countries (HIC), with LMIC respondents comprising 51% of respondents. There is heterogeneity across the diagnostic processes, including clinical assessment, where 30% (389) did not consider radiological evidence essential to diagnose pneumonia, variable collection of microbiological samples, and use and practice in bronchoscopy. Microbiological diagnostics were least frequently available in low and lower-middle-income nation settings. Modal intended antibiotic treatment duration was 5–7 days for all types of pneumonia. Shorter durations of antibiotic treatment were associated with antimicrobial stewardship (AMS) programs, high national income status, and formal intensive care training.
Conclusions
This study highlighted variations in clinical practice and diagnostic capabilities for pneumonia, particularly issues with access to diagnostic tools in LMICs were identified. There is a clear need for improved adherence to existing guidelines and standardized approaches to diagnosing and treating pneumonia in the ICU.
Key Points:
- Scope of Study: The survey included ICU clinicians from HICs (49%) and LMICs (51%), assessing practices in diagnosing and treating pneumonia.
- Diagnostic Practices: Only 65% of clinicians required both clinical and radiological criteria for pneumonia diagnosis, with radiological reliance lower for HAP and VAP compared to CAP.
- Microbiological Sampling: Sputum and endotracheal aspirates were the most common diagnostic samples, though bronchoalveolar lavage (BAL) usage varied, especially in LMICs.
- Antibiotic Stewardship: Antimicrobial stewardship (AMS) programs were associated with shorter antibiotic treatment durations and better adherence to protocols.
- Treatment Variability: Dual antibiotic therapy with macrolides was preferred for CAP, whereas HAP and VAP protocols emphasized coverage for resistant organisms.
- Resource Disparities: LMICs reported significant limitations in advanced diagnostic tools like lung ultrasound and multiplex molecular testing.
- Bronchoscopy Availability: Only 61% of LMIC facilities had bronchoscopy, compared to 97% in HICs, with restricted availability and training in LMICs.
- Antibiotic Duration: Most clinicians adhered to recommended 5–7 days for CAP, but extended durations were common for HAP and VAP, particularly in LMICs.
- Guideline Gaps: Deviations from international guidelines were frequent, often due to resource constraints and training gaps.
- Global Insights: The study highlights the need for standardized practices and improved diagnostic and treatment access across all income settings.
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