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.

Read Craven and Niederman's official comments in Lancet ID.

Read Kett et al's response in Lancet ID. 

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)