A Randomized Crossover Trial Evaluating the Impact of Cultural Dexterity Training on Surgical Residents' Knowledge, Cross-Cultural Care, Skills, and Beliefs: The Provider Awareness and Cultural dexterity Training for Surgeons (PACTS) Trial.

OBJECTIVES: This trial examines the impact of the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum on surgical residents' knowledge, cross-cultural care, skills, and beliefs. SUMMARY BACKGROUND DATA: Cross-cultural training of providers may reduce healthcare outcome disparities, but its effectiveness in surgical trainees is unknown. METHODS: PACTS focuses on developing skills needed for building trust, working with patients with limited English proficiency, optimizing informed consent, and managing pain. The PACTS trial was a randomized crossover trial of 8 academic general surgery programs in the United States: The Early group ("Early") received PACTS between Periods 1 and 2, while the Delayed group ("Delayed") received PACTS between Periods 2 and 3. Residents were assessed pre- and post-intervention on Knowledge, Cross-Cultural Care, Self-Assessed Skills, and Beliefs. Chi-square and Fisher's exact tests were conducted to evaluate within- and between-intervention group differences. RESULTS: Of 406 residents enrolled, 315 were exposed to the complete PACTS curriculum. Early residents' Cross-Cultural Care (79.6% to 88.2%, P<0.0001), Self-Assessed Skills (74.5% to 85.0%, P<0.0001), and Beliefs (89.6% to 92.4%, P=0.0028) improved after PACTS; Knowledge scores (71.3% to 74.3%, P=0.0661) were unchanged. Delayed resident scores pre- to post-PACTS showed minimal improvements in all domains. When comparing the two groups at Period 2, Early residents had modest improvement in all 4 assessment areas, with statistically significant increase in Beliefs (92.4% vs 89.9%, P=0.0199). CONCLUSION: The PACTS curriculum is a comprehensive tool that improved surgical residents' knowledge, preparedness, skills, and beliefs, which will help with caring for diverse patient populations.

Controversies in Perioperative Antimicrobial Prophylaxis.

Although clinical guidelines for antibiotic prophylaxis across a wide array of surgical procedures have been proposed by multidisciplinary groups of physicians and pharmacists, clinicians often deviate from recommendations. This is particularly true when recommendations are based on weak data or expert opinion. The goal of this review is to highlight certain common but controversial topics in perioperative prophylaxis and to focus on the data that does exist for the recommendations being made.

Trial of short-course antimicrobial therapy for intraabdominal infection.

BACKGROUND: The successful treatment of intraabdominal infection requires a combination of anatomical source control and antibiotics. The appropriate duration of antimicrobial therapy remains unclear. METHODS: We randomly assigned 518 patients with complicated intraabdominal infection and adequate source control to receive antibiotics until 2 days after the resolution of fever, leukocytosis, and ileus, with a maximum of 10 days of therapy (control group), or to receive a fixed course of antibiotics (experimental group) for 4±1 calendar days. The primary outcome was a composite of surgical-site infection, recurrent intraabdominal infection, or death within 30 days after the index source-control procedure, according to treatment group. Secondary outcomes included the duration of therapy and rates of subsequent infections. RESULTS: Surgical-site infection, recurrent intraabdominal infection, or death occurred in 56 of 257 patients in the experimental group (21.8%), as compared with 58 of 260 patients in the control group (22.3%) (absolute difference, -0.5 percentage point; 95% confidence interval [CI], -7.0 to 8.0; P=0.92). The median duration of antibiotic therapy was 4.0 days (interquartile range, 4.0 to 5.0) in the experimental group, as compared with 8.0 days (interquartile range, 5.0 to 10.0) in the control group (absolute difference, -4.0 days; 95% CI, -4.7 to -3.3; P<0.001). No significant between-group differences were found in the individual rates of the components of the primary outcome or in other secondary outcomes. CONCLUSIONS: In patients with intraabdominal infections who had undergone an adequate source-control procedure, the outcomes after fixed-duration antibiotic therapy (approximately 4 days) were similar to those after a longer course of antibiotics (approximately 8 days) that extended until after the resolution of physiological abnormalities. (Funded by the National Institutes of Health; STOP-IT ClinicalTrials.gov number, NCT00657566.).

Development and Implementation of a School-Wide Institute for Excellence in Education to Enable Educational Scholarship by Medical School Faculty.

PROBLEM: Educational scholarship is an important component for faculty at Academic Medical Centers, especially those with single-track promotion systems. Yet, faculty may lack the skills and mentorship needed to successfully complete projects. In addition, many educators feel undervalued. INTERVENTION: To reinvigorate our school's educational mission, the Institute for Excellence in Education (IEE) was created. Here we focus on one of the IEE's strategic goals, that of inspiring and supporting educational research, scholarship, and innovation. CONTEXT: Using the 6-step curriculum development process as a framework, we describe the development and outcomes of IEE programs aimed at enabling educational scholarship at the Johns Hopkins University School of Medicine. OUTCOME: Four significant programs that focused on educational scholarship were developed and implemented: (a) an annual conference, (b) a Faculty Education Scholars' Program, (c) "Shark Tank" small-grant program, and (d) Residency Redesign Challenge grants. A diverse group of primarily junior faculty engaged in these programs with strong mentorship, successfully completing and disseminating projects. Faculty members have been able to clarify their personal goals and develop a greater sense of self-efficacy for their desired paths in teaching and educational research. LESSONS LEARNED: Faculty require programs and resources for educational scholarship and career development, focused on skills building in methodology, assessment, and statistical analysis. Mentoring and the time to work on projects are critical. Key to the IEE's success in maintaining and building programs has been ongoing needs assessment of faculty and learners and a strong partnership with our school's fund-raising staff. The IEE will next try to expand opportunities by adding additional mentoring capacity and further devilment of our small-grants programs.

Executive Summary: Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.

Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.

Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.

Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.

Duty hours and perceived competence in surgery: are interns ready?

BACKGROUND: A fundamental shift in the structure of many surgical training programs has occurred after the July 2011 rule changes. Our intern didactic program was intensified in 2011 with targeted lectures, laboratories, and clinical cases as well as direct supervision until competency was achieved for basic clinical problems. We sought to compare interns' perceived preparedness throughout and at the end of the academic years before and after July 2011. MATERIALS AND METHODS: Intern perceptions of preparedness to manage common clinical scenarios and perform procedures in general surgery were serially surveyed in academic years ending in 2011 and 2012 based on the Residency Review Committee supervision guidelines. RESULTS: Interns felt less prepared across all measured domains from 2011-2012. Interns felt significantly less prepared to manage hypotension (3.00/4 points to 2.67/4 points; P=0.04), place a tube thoracostomy (2.45/4 points to 1.92/4 points; P=0.04), or perform an inguinal hernia repair (1.91/4 points to 0.92/4 points; P=0.01) without supervision. Interns were also significantly less likely to agree that they were able to gain clinical skills based on experience (4.31/5 points versus 4.15/5 points; P=0.02). Longitudinal analysis throughout internship demonstrated improved preparedness to manage common clinical problems and perform procedures between the second and the fifth months of internship. CONCLUSIONS: First-year residents after July 2011 felt less prepared in the topics surveyed than those before July 2011. Interns made the greatest gains in preparedness between months 2 and 5, suggesting that despite planned interventions, no substitute currently exists for actual clinical experience. Planned educational interventions to improve intern preparedness are also indicated.

Disparities in Medical School Clerkship Grades Associated with Sex, Race, and Ethnicity: A Person-Centered Approach.

PURPOSE: To determine whether students' self-reported race/ethnicity and sex were associated with grades earned in 7 core clerkships. A person-centered approach was used to group students based on observed clerkship grade patterns. Predictors of group membership and predictive bias by race/ethnicity and sex were investigated. METHOD: Using data from 6 medical student cohorts at Johns Hopkins University School of Medicine (JHUSOM), latent class analysis was used to classify students based on clerkship grades. Multinomial logistic regression was employed to investigate if preclerkship measures and student demographic characteristics predicted clerkship performance-level groups. Marginal effects for United States Medical Licensing Exam (USMLE) Step 1 scores were obtained to assess the predictive validity of the test on group membership by race/ethnicity and sex. Predictive bias was examined by comparing multinomial logistic regression prediction errors across racial/ethnic groups. RESULTS: Three clerkship performance-level groups emerged from the data: low, middle, and high. Significant predictors of group membership were race/ethnicity, sex, and USMLE Step 1 scores. Black or African American students were more likely (odds ratio [OR] = 4.26) to be low performers than White students. Black or African American (OR = 0.08) and Asian students (OR = 0.41) were less likely to be high performers than White students. Female students (OR = 2.51) were more likely to be high performers than male students. Patterns of prediction errors observed across racial/ethnic groups showed predictive bias when using USMLE Step 1 scores to predict clerkship performance-level groups. CONCLUSIONS: Disparities in clerkship grades associated with race/ethnicity were found among JHUSOM students, which persisted after controlling for USMLE Step 1 scores, sex, and other preclerkship performance measures. Differential predictive validity of USMLE Step 1 exam scores and systematic error predictions by race/ethnicity show predictive bias when using USMLE Step 1 scores to predict clerkship performance across racial/ethnic groups.

Changing Surgical Culture Through Surgical Education: Introduction to the PACTS Trial.

The Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum was developed to improve surgical resident cultural dexterity, with the goal of promoting health equity by developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care through structured educational interventions for surgical residents. Funded by the National Institute of Health (NIH)'s National Institute on Minority Health and Health Disparities, PACTS addresses surgical disparities in patient care by incorporating varied educational interventions, with investigation of both traditional and nontraditional educational outcomes such as patient-reported and clinical outcomes, across multiple hospitals and regions. The unique attributes of this multicenter, multiphased research trial will not only impact future surgical education research, but hopefully improve how surgeons learn nontechnical skills that modernize surgical culture and surgical care. The present perspective piece serves as an introduction to this multifaceted surgical education trial, highlighting the rationale for the study and critical curricular components such as key stakeholders from multiple institutions, multimodal learning and feedback, and diverse educational outcomes.

American College of Surgeons Objective Assessment of Skills in Surgery (ACS OASIS): A Formative Assessment of Junior Residents' Technical Skills.

OBJECTIVE: The objective assessment of technical skills of junior residents is essential in implementing competency-based training and providing specific feedback regarding areas for improvement. An innovative assessment that can be easily implemented by training programs nationwide has been developed by expert surgeon educators under the aegis of the American College of Surgeons (ACS) Division of Education. This assessment, ACS Objective Assessment of Skills in Surgery (ACS OASIS) uses eight stations to address technical skills important for junior residents within the domains of laparoscopic appendectomy, excision of lipoma, central line placement, laparoscopic cholecystectomy, trocar placement, exploratory laparotomy, repair of enterotomy, and tube thoracostomy. The purpose of this study was to implement ACS OASIS at a number of sites to study its psychometric rigor. DESIGN: The ACS OASIS was pre-piloted at two programs to establish feasibility and to gather information regarding implementation. Each skills station was 12 minutes long, and the faculty completed a checklist with 5 to 15 items, and a global assessment scale. The study was then repeated at three pilot sites and included 29 junior residents who were assessed by a total of 44 faculty. Psychometric data for the stations and checklists were collected and analyzed. SETTING: The pre-pilot sites were Geisinger and University of Tennessee Knoxville.Data were gathered from pilot sites that included Wellspan Health, Duke University, and University of California Los Angeles. RESULTS: The mean checklist score for all learners was 76% (IQR of 66%-85%). The average global rating was 3.36 on a 5-point scale with a standard deviation of 0.56. The overall cut score derived using the borderline group method was at 68% with 34% of performances requiring remediation. Using this criterion, the average number of stations that were completed by each learner without need for remediation was five.The station discrimination index ranged from 0.27 to 0.65 (all above the threshold of 0.25), demonstrating solid psychometric characteristics at the station level. The internal-consistency reliability was 0.76 with SEM of 5.8%. The inter-rater reliability (intraclass correlation) was high at 0.73 with general agreement of 79% between the two raters. The station discrimination was at 0.45 (range of 0.27 to 0.65) indicating a high level of differentiation between high and low performers. Using the generalizability theory, the G-coefficient reliability was at 0.72 with the reliability projection flattening after 8 stations. Overall, 75% to 82% the faculty and learners rated ACS OASIS as realistic and beneficial. CONCLUSIONS: ACS OASIS is a psychometrically sound technical skills assessment tool that can provide useful information for feedback to junior residents and support efforts to remediate gaps in performance.

Association of unconscious race and social class bias with vignette-based clinical assessments by medical students.

CONTEXT: Studies involving physicians suggest that unconscious bias may be related to clinical decision making and may predict poor patient-physician interaction. The presence of unconscious race and social class bias and its association with clinical assessments or decision making among medical students is unknown. OBJECTIVE: To estimate unconscious race and social class bias among first-year medical students and investigate its relationship with assessments made during clinical vignettes. DESIGN, SETTING, AND PARTICIPANTS: A secure Web-based survey was administered to 211 medical students entering classes at Johns Hopkins School of Medicine, Baltimore, Maryland, in August 2009 and August 2010. The survey included the Implicit Association Test (IAT) to assess unconscious preferences, direct questions regarding students' explicit race and social class preferences, and 8 clinical assessment vignettes focused on pain assessment, informed consent, patient reliability, and patient trust. Adjusting for student demographics, multiple logistic regression was used to determine whether responses to the vignettes were associated with unconscious race or social class preferences. MAIN OUTCOME MEASURES: Association of scores on an established IAT for race and a novel IAT for social class with vignette responses. RESULTS: Among the 202 students who completed the survey, IAT responses were consistent with an implicit preference toward white persons among 140 students (69%, 95% CI, 61%-75%). Responses were consistent with a preference toward those in the upper class among 174 students (86%, 95% CI, 80%-90%). Assessments generally did not vary by patient race or occupation, and multivariable analyses for all vignettes found no significant relationship between implicit biases and clinical assessments. Regression coefficient for the association between pain assessment and race IAT scores was -0.49 (95% CI, -1.00 to 0.03) and for social class, the coefficient was -0.04 (95% CI, -0.50 to 0.41). Adjusted odds ratios for other vignettes ranged from 0.69 to 3.03 per unit change in IAT score, but none were statistically significant. Analysis stratified by vignette patient race or class status yielded similarly negative results. Tests for interactions between patient race or class status and student IAT D scores in predicting clinical assessments were not statistically significant. CONCLUSIONS: The majority of first-year medical students at a single school had IAT scores consistent with implicit preference for white persons and possibly for those in the upper class. However, overall vignette-based clinical assessments were not associated with patient race or occupation, and no association existed between implicit preferences and the assessments.

The Challenges of Program Accreditation Decisions in 2021 for the ACMGE Review Committee for Surgery.

Through only a few months, the COVID-19 pandemic has greatly impacted the daily activities and education of surgical residents and fellows and the programs in which they are enrolled. The pandemic has also forced many changes for the Accreditation Council for Graduate Medical Education and its Review Committee for Surgery. This article details some of those changes and their effect on the process of conferring 2021 accreditation decisions by the Review Committee.

A Qualitative Study of the Barriers and Benefits to Resident Education in Ambulatory Surgical Centers.

OBJECTIVE: As Ambulatory Surgical Centers (ASCs) become more common in academic medical centers, large hospital systems must determine how to shift resident education from inpatient to outpatient surgical centers. This study aims to define stakeholders' views regarding the integration of surgical residents into ASCs. DESIGN: Long-form interviews lasting 30 to 60 minutes were conducted. Interviews were hand-transcribed and analyzed by qualitative analysis to determine benefits of learning in ASCs for residents, challenges that arise from integrating residents, and recommendations to improve resident incorporation. SETTING: Interviews were conducted using a video conferencing platform. PARTICIPANTS: Residency program directors, attending surgeons, graduate medical learners, and a nursing manager were interviewed. Twenty-one total interviews were conducted, representing ten different departments. RESULTS: Stakeholders agreed that residents benefit from being placed in ASCs because the fast, surgical pace allows the residents to engage in more cases. However, different stakeholders highlighted different challenges, all centered around the notion of inter-stakeholder conflict due to conflicting priorities among residents, attending physicians, and administration. Likewise, recommendations differed by stakeholder group-faculty members sought more defined learning objectives and enhanced communication, whereas residents desired that ambulatory surgical time be more structured. CONCLUSIONS: Despite the pressures of rapid case turnover, stakeholders agreed that there are many benefits to resident education in ASCs. Findings related to challenges and recommendations support the need to strengthen communication between stakeholder groups and better plan for resident integration into ASCs.

Aminoglycoside Dosing and Volume of Distribution in Critically Ill Surgery Patients.

Background: At a tertiary referral and Level I trauma center, current institutional guidelines suggest initial aminoglycoside doses of gentamicin or tobramycin 4 mg/kg and amikacin 16 mg/kg for patients admitted to surgical intensive care units (SICUs) with suspected gram-negative infection. The objective of this study was to evaluate initial aminoglycoside dosing and peak serum drug concentrations in critically ill surgery patients to characterize the aminoglycoside volume of distribution (Vd) and determine an optimal standardized dosing strategy. Methods: This retrospective, observational, single-center study included adult SICU patients who received an aminoglycoside for additional gram-negative coverage. Descriptive statistics were used to evaluate the patient population, aminoglycoside dosing, and Vd. Multivariable linear regression was applied to determine variables associated with greater aminoglycoside Vd. The mortality rate was compared in patients who achieved adequate initial peak concentrations versus those who did not. Results: One hundred seventeen patients received an aminoglycoside in the SICUs, of whom 58 had an appropriately timed peak concentration measurement. The mean Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II score was 27.8 ± 8.9. The Vd in patients receiving gentamicin, tobramycin, and amikacin was 0.49 ± 0.10, 0.41 ± 0.09, and 0.53 ± 0.13 L/kg, respectively. Together, the mean aminoglycoside Vd was 0.50 ± 0.12 L/kg. Gentamicin or tobramycin 5 mg/kg achieved goal peak concentrations in 24 patients (63.2%), and amikacin 20 mg/kg achieved the desired concentrations in nine patients (50.0%). Net fluid status, Body Mass Index, and vasopressor use were not predictive of Vd. There was no difference in the in-hospital mortality rate in patients who achieved adequate peak concentrations versus those who did not (26.8% versus 26.7%; p = 0.99). Conclusion: High aminoglycoside doses are needed in critically ill surgery patients to achieve adequate initial peak concentrations because of the high Vd. Goal peak concentrations were optimized at doses of gentamicin or tobramycin 5 mg/kg, and amikacin 20 mg/kg.

Concordance of Resident and Patient Perceptions of Culturally Dexterous Patient Care Skills.

PURPOSE: Disparities in surgical care persist. To mitigate these disparities, we are implementing and testing the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS), a curriculum to improve surgical residents' cultural dexterity during clinical encounters. We analyzed baseline data to look for concordance between residents' self-perceived cultural dexterity skills and patients' perceptions of their skills. We hypothesized that residents would rate their skills in cultural dexterity higher than patients would perceive those skills. METHODS: Prior to the implementation of the curriculum, surgical residents at 5 academic medical centers completed a self-assessment of their skills in culturally dexterous patient care using a modified version of the Cross-Cultural Care Survey. Randomly selected surgical inpatients at these centers completed a similar survey about the quality of culturally dexterous care provided by a surgery resident on their service. Likert scale responses for both assessments were classified as high (agree/strongly agree) or low (neutral/disagree/strongly disagree) competency. Resident and patient ratings of cultural dexterity were compared. Assessments were considered dexterous if 75% of responses were in the high category. Univariate and multivariate analysis was conducted using STATA 16. RESULTS: A total of 179 residents from 5 surgical residency programs completed self-assessments prior to receiving the PACTS curriculum, including 88 (49.2%) women and 97 (54.2%) junior residents (PGY 1-2s), of whom 54.7% were White, 19% were Asian, and 8.9% were Black/African American. A total of 494 patients with an average age of 55.1 years were surveyed, of whom 238 (48.2%) were female and 320 (64.8%) were White. Fifty percent of residents viewed themselves as culturally dexterous, while 57% of patients reported receiving culturally dexterous care; this difference was not statistically significant (p = 0.09). Residents who perceived themselves to be culturally dexterous were more likely to self-identify as non-White as compared to White (p < 0.05). On multivariate analysis, White patients were more likely to report highly dexterous care, whereas Black patients were more likely to report poorly dexterous care (p < 0.05). CONCLUSIONS: At baseline, half of patients reported receiving culturally dexterous care from surgical residents at 5 academic medical centers in the United States. This was consistent with residents' self-assessment of their cultural dexterity skills. White patients were more likely to report receiving culturally dexterous care as compared to non-White patients. Non-White residents were more likely to feel confident in their cultural dexterity skills. A novel curriculum has been designed to improve these interactions between patients and surgical residents.

The epidemiology of Candida colonization and invasive candidiasis in a surgical intensive care unit where fluconazole prophylaxis is utilized: follow-up to a randomized clinical trial.

OBJECTIVE: To determine whether Candida glabrata colonization and invasive candidiasis (IC) increased among critically ill surgical patients 3 years after the introduction of fluconazole prophylaxis to a surgical intensive care unit (SICU). SUMMARY BACKGROUND DATA: Fluconazole prophylaxis has been shown in randomized clinical trials to reduce the occurrence of candidiasis in some patient populations, including high-risk SICU patients. One such trial was performed in The Johns Hopkins Hospital SICU in 1998. Whether the epidemiology of Candida colonization and IC has changed in SICUs where fluconazole prophylaxis is routinely utilized has not been adequately studied. METHODS: We conducted a prospective, observational study of subjects admitted for > or = 3 days to the SICU of a large, urban, academic medical center, where fluconazole prophylaxis had been utilized for approximately 3 years. Surveillance fungal cultures of rectal/fecal swabs, urine, and endotracheal aspirates were performed on admission to the SICU, once weekly, and upon discharge from the SICU. Demographic and clinical data were collected. C. glabrata colonization and IC prevalence among patients in the prospective cohort were compared with the prevalence among SICU patients enrolled in the 1998 clinical trial of fluconazole for the prevention of candidiasis that was performed at the same institution. RESULTS: C. glabrata colonization was not significantly more common among patients in the 2003 cohort as compared with patients in the 1998 trial (adjusted odds ratio [OR]: 0.90, 95% confidence interval [CI]: 0.57-1.41). Patients with IC in the 2003 cohort were not more likely than those in the 1998 trial to have IC due to C. glabrata (adjusted OR: 1.93, 95% CI: 0.20-18.98), while patients with IC in the 2003 cohort were less likely than patients in the 1998 trial to have acquired IC in the ICU (adjusted OR: 0.08, 95% CI: 0.009-0.82). CONCLUSIONS: There was no increase in C. glabrata colonization or in the proportion of IC due to C. glabrata after a 3-year period of routine fluconazole prophylaxis for selected SICU patients.

Hospital-acquired pneumonia: pathophysiology, diagnosis, and treatment.

Hospital-acquired pneumonia (HAP) is one of the most common causes of nosocomial infection, morbidity, and mortality in hospitalized patients. Many patient- and disease-specific factors contribute to the pathophysiology of HAP, particularly in the surgical population. Risk-factor modification and inpatient prevention strategies can have a significant impact on the incidence of HAP. While the best diagnostic strategy remains a subject of some debate, prompt and appropriate antimicrobial therapy in patients suspected of having HAP has been shown to significantly decrease mortality. Because the pathogens responsible for HAP are frequently more virulent and have greater resistance to commonly used antimicrobials than other pathogens, clinicians must have knowledge of the resistance patterns at their institutions to choose appropriate therapy.