Resource use by patients hospitalized with community-acquired pneumonia in Europe: analysis of the REACH study (original) (raw)
European Respiratory Journal, 2012
Do physicians apply an early-switch strategy (from intravenous to oral antibiotics) in clinically stable patients hospitalised with community-acquired pneumonia (CAP)? If not, why not? In a multicentre prospective cohort study, adult patients admitted for i.v. CAP treatment were included. On day 3 of antibiotic treatment, clinical stability was assessed and treating resident physicians were interviewed on their switch strategies. Additionally, treating physicians were interviewed to evaluate their knowledge of and adherence to guideline advice. 149 (92%) out of 162 patients were included and 97 (91%) out of 107 physicians were interviewed. A switch to oral antibiotics was possible in 68 (46%) out of 149 patients on day 3 of treatment but not performed in 27 (40%) out of 68. Patient factors delaying the switch were high CURB-65 (confusion of new onset, urea .7 mmol?L-1 , respiratory rate of o30 breaths?min-1 , blood pressure ,90 mmHg or diastolic blood pressure f60 mmHg, and age o65 yrs) score (on admission) (p50.04) and oxygen treatment (p50.04), high temperature (p50.00) and high respiration rate (p50.04) (day 3). Physicians' barriers to an early switch in clinically stable patients included misconceptions (26 (55%) out of 47), practical considerations (13 (28%) out of 47) and organisational factors (eight (17%) out of 47). Strikingly, 91 (94%) out of 97 interviewed physicians were not aware of guideline advice. The switch from i.v. to oral antibiotics is often unnecessarily delayed in patients hospitalised with CAP due to different types of barriers.
Background: The optimal duration of antibiotic treatment for community-acquired pneumonia (CAP) is not well established. The aim of this study was to assess the impact of reducing the duration of antibiotic treatment on long-term prognosis in patients hospitalized with CAP. Methods: This was a multicenter study assessing complications developed during 1 year of patients previously hospitalized with CAP who had been included in a randomized clinical trial concerning the duration of antibiotic treatment. Mortality at 90 days, at 180 days and at 1 year was analyzed, as well as new admissions and cardiovascular complications. A subanalysis was carried out in one of the hospitals by measuring C-reactive protein (CRP), procalcitonin (PCT) and proadrenomedullin (proADM) at admission, at day 5 and at day 30. Results: A total of 312 patients were included, 150 in the control group and 162 in the intervention group. Ninety day, 180 day and 1-year mortality in the per-protocol analysis were 8 (2.57%), 10 (3.22%) and 14 (4.50%), respectively. There were no significant differences between both groups in terms of 1-year mortality (p = 0.94), new admissions (p = 0.84) or cardiovascular events (p = 0.33). No differences were observed between biomarker level differences from day 5 to day 30 (CRP p = 0.29; PCT p = 0.44; proADM p = 0.52). Conclusions: Reducing antibiotic treatment in hospitalized patients with CAP based on clinical stability criteria is safe, without leading to a greater number of long-term complications.
A Prospective Randomized Study of Inpatient IV Antibiotics for Community-Acquired Pneumonia
CHEST Journal, 1996
Study objective: To compare therapeutic outcome and perform a cost-benefit analysis of inpatients with community-acquired pneumonia (CAP) treated with a shortened course of IV antibiotic ther¬ apy. Design: A prospective, randomized, parallel group study with a follow-up period of 28 days. Setting: Bronx Veterans Affairs Medical Center (VAMC) and the Castle Point VAMC; universityaffiliated VAMC general medical wards from September 1993 to March 1995. Patients: Seventy-two male veterans and 1 female veteran with 75 episodes of CAP defined by a new infiltrate on chest radiograph and either history or physical findings consistent with pneumonia. Study population was 42%(31) black, 33%(24) white, and 25%(18) Hispanic. Interventions: Patients were randomized (1:1:1) to 1 of 3 treatment groups: group 1 received 2 days of IV and 8 days of oral therapy; group 2 received 5 days of IV and 5 days of oral therapy; and group 3 received 10 days of IV therapy. Antibiotics consisted of cefuroxime, 750 mg every 8 h for the IV course, and cefuroxime axetil, 500 mg every 12 h for the oral therapy. Measurements and results: No differences were found in the clinical course, cure rates, or resolu¬ tion of chest radiograph abnormalities among the three groups. A significant difference was found in the length of stay (LOS) among the three groups. The mean±SD LOS was 6±3 days in group 1, 8±2 days in group 2, and 11 ±1 days in group 3. The shortened LOS could potentially save 95.5millionfortheDepartmentofVeteransAffairsand95.5 million for the Department of Veterans Affairs and 95.5millionfortheDepartmentofVeteransAffairsand2.9 billion for the US private sector. Conclusions: Adult patients hospitalized for CAP who are not severely ill can be successfully treated with an abbreviated (2-day) course of IV antibiotics and then switched to oral therapy. A longer course of IV therapy prolongs hospital stay and cost, without improving the therapeutic cure rate.
Journal of Forensic Medicine, 2021
Background: Community-Acquired Pneumonia (CAP) is a lower respiratory tract infection with bacteriaas the most frequent causative agent. Therapy for pneumonia includes appropriate antibiotic usage.Inappropriate antibiotic use supposedly increase 30-days readmission and mortality rate.Objective: To evaluate the antibiotic use and the impact of appropriate antibiotic use on the 30-daysreadmission and mortality of CAP patients in inpatient non-ICU settings.Method: A cross-sectional, analytic study was conducted. We collected data from Universitas Airlanggahospital’s medical record to obtain the details of antibiotic usage. Result were evaluated using the Gyssensalgorithm. A chi-square test was used to identify the impact of appropriate antibiotic use on the 30-daysreadmission and mortality.Result: A total of 90 patients with CAP fulfilled the inclusion criteria. One gram of ceftriaxone IV wasthe most prescribed antibiotic for therapy of CAP. The amount of appropriate antibiotic use is ...
Chest Journal, 1996
Study objective: To compare therapeutic outcome and perform a cost-benefit analysis of inpatients with community-acquired pneumonia (CAP) treated with a shortened course of IV antibiotic ther¬ apy. Design: A prospective, randomized, parallel group study with a follow-up period of 28 days. Setting: Bronx Veterans Affairs Medical Center (VAMC) and the Castle Point VAMC; universityaffiliated VAMC general medical wards from September 1993 to March 1995. Patients: Seventy-two male veterans and 1 female veteran with 75 episodes of CAP defined by a new infiltrate on chest radiograph and either history or physical findings consistent with pneumonia. Study population was 42%(31) black, 33%(24) white, and 25%(18) Hispanic. Interventions: Patients were randomized (1:1:1) to 1 of 3 treatment groups: group 1 received 2 days of IV and 8 days of oral therapy; group 2 received 5 days of IV and 5 days of oral therapy; and group 3 received 10 days of IV therapy. Antibiotics consisted of cefuroxime, 750 mg every 8 h for the IV course, and cefuroxime axetil, 500 mg every 12 h for the oral therapy. Measurements and results: No differences were found in the clinical course, cure rates, or resolu¬ tion of chest radiograph abnormalities among the three groups. A significant difference was found in the length of stay (LOS) among the three groups. The mean±SD LOS was 6±3 days in group 1, 8±2 days in group 2, and 11 ±1 days in group 3. The shortened LOS could potentially save 95.5millionfortheDepartmentofVeteransAffairsand95.5 million for the Department of Veterans Affairs and 95.5millionfortheDepartmentofVeteransAffairsand2.9 billion for the US private sector. Conclusions: Adult patients hospitalized for CAP who are not severely ill can be successfully treated with an abbreviated (2-day) course of IV antibiotics and then switched to oral therapy. A longer course of IV therapy prolongs hospital stay and cost, without improving the therapeutic cure rate.
Managing CAP patients at risk of clinical failure
Respiratory Medicine, 2015
Community-acquired pneumonia (CAP) is a curable disease. Both the European and American clinical practice guidelines provide algorithms how to manage patients with CAP. However, as populations worldwide are ageing and bacteria are becoming multidrug resistant, it is necessary to address the major factors that put patients at risk of poor outcome. These may include age, comorbidities, the settings where pneumonia was acquired or treated, the need for hospitalisation or ICU admission, likely causative pathogen (bacteria or virus) in a certain region and their local susceptibility pattern. One complicating fact is the lack of definite causative pathogen in approximately 50% of patients making it difficult to choose the most appropriate antibiotic treatment. When risk factors are present simultaneously in patients, fewer treatment options could be rather challenging for physicians. For example, the presence of comorbidities (renal, cardiac, hepatic) may exclude certain antibiotics due to potential adverse events. Assessing the severity of the disease and monitoring biomarkers, however, could help physicians to estimate patient prognosis once diagnosis is confirmed and treatment has been initiated. This review article addresses the most important risk factors of poor outcome in CAP patients.
2010
Objective: This study evaluated the survival benefit of US community-acquired pneumonia (CAP) practice guidelines in the intensive care unit (ICU) setting. Methods: We conducted a retrospective cohort study of adult patients with CAP who were admitted to 5 community hospital ICUs between November 1, 1999, and April 30, 2000. The guidelines for antibiotic prescriptions were the 2007 Infectious Diseases Society of America/American Thoracic Society guidelines. Guideline-concordant antimicrobial therapy was defined as a β-lactam plus fluoroquinolone or macrolide, antipseudomonal β-lactam plus fluoroquinolone, or antipseudomonal β-lactam plus aminoglycoside plus fluoroquinolone or macrolide. Patients with a documented β-lactam allergy were considered to have received guideline-concordant therapy if they received a fluoroquinolone with or without clindamycin, or aztreonam plus fluoroquinolone with or without aminoglycoside. All other antibiotic regimens were considered to be guideline discordant. Time to clinical stability, time to oral antibiotics, length of hospital stay, and in-hospital mortality were evaluated with regression models that included the outcome as the dependent variable, guidelineconcordant antibiotic therapy as the independent variable, and the Pneumonia Severity Index (PSI) score and facility as covariates. Results: The median age of the 129 patients included in the study was 71 years (interquartile range, 60-79 years). Sixty-two of 129 patients (48%) were male. Comorbidities included liver dysfunction (7 patients [5%]), heart failure (62 [48%]), renal dysfunction (39 [30%]), cerebrovascular disease (21 [16%]), and cancer (14 [11%]). The median (25th-75th percentile) PSI score was 119 (98-142), and overall mortality was 19% (25 patients). Patient demographics were similar between groups. Fifty-three patients (41%) received guideline-endorsed therapies. Guideline-discordant therapy was associated with an increase in inpatient mortality (25% vs 11%; odds ratio = 2.99 [95% CI, 1.08-9.54]). Receipt of guideline-concordant antibiotics was not associated with reductions in time to clinical stability, time to oral antibiotics, or length of hospital stay when patients who died were excluded from the analysis. Conclusion: Guideline-concordant empiric antibiotic therapy was associated with improved survival among these patients with CAP who were admitted to 5 ICUs.
Antibiotic therapy for inpatients with community-acquired pneumonia in a developing country
Pharmacoepidemiology and Drug Safety, 2014
Purpose The aim of this study was to identify antibiotic prescription patterns for community-acquired pneumonia (CAP) in Vietnam. Methods Medical records for CAP adult patients admitted to 10 hospitals across the country were randomly selected from admission lists during the peak pneumonia season. CAP cases were identified from manual record reviews by clinical pharmacists. Data was collected using a standard data collection tool including patient clinical features on admission, comorbidities, microbiological culture results, and antibiotic regimens. Pneumonia severity was estimated using the CURB-65 score. Results A total of 649 medical records for adult patients (55.2% male and 52.3% urban residents, median age 68 years) met the selection criteria for CAP. Pneumonia severity was assessed as mild (64.1% of patients), moderate (23.0%), and severe (9.2%). Antibiotics were most frequently administered intravenously (93.4%) and as combination therapy (dual therapy 54.4%, monotherapy 42.5%, and triple therapy 3.1% of patients) regardless of CAP severity. Third-generation cephalosporins were used most frequently (29.3% as monotherapy and 40.4% as combination therapy). Third-generation cephalosporins were most commonly combined with penicillins and/or quinolones. Conclusions This first nationwide study provides a baseline profile of antibiotic use in the treatment of CAP. Third-generation cephalosporins were widely used for initial empirical management of CAP, often in combination with quinolones, regardless of CAP severity. The study will assist in providing an evidence base to inform new national antibiotic guidelines for CAP management and will contribute locally relevant data for the national master plan addressing antibiotic resistance and the development of educational interventions to improve CAP management.
Clinical Infectious Diseases, 2012
Background. Initial management of community-acquired pneumonia (CAP) has been a Centers for Medicare and Medicaid Services performance measure for a decade. We hypothesized that an intervention directed at management of CAP that assesses areas not covered by the performance measures-treatment duration and antimicrobial selection after additional microbiology data are available-would further improve CAP management. Methods. We performed a single-center, prospective study to compare management of adult inpatients with presumed CAP before (from 1 January 2008 through 31 March 2008) and after (from 1 February 2010 through 10 May 2010) an intervention consisting of education and prospective feedback to teams regarding antibiotic choice and duration. The primary outcome measure was duration of antibiotic therapy in the 2 periods. Results. There were 62 patients in the preintervention period and 65 patients in the intervention period. The duration of antibiotic therapy decreased from a median of 10 to 7 days (P , .001), with 148 fewer days of antibiotic therapy. The median lengths of stay were similar in the 2 groups (4 vs 5 days). A causative pathogen was identified less frequently during the intervention period (14% vs 34%); however, antibiotics were more frequently narrowed or modified on the basis of susceptibility results during the intervention period (67% vs 19%). Fewer patients received duplicate therapy within 24 hours in the intervention period (90% vs 55%). Conclusions. The duration of therapy for CAP was excessive at our institution and was decreased with a stewardship intervention. Confirmatory studies at other institutions are needed; efforts to assess and reduce duration of therapy for CAP should be strongly considered.
Clinical Microbiology and Infection, 2012
The effects of antibiotic timing on outcomes of patients with community-acquired pneumonia (CAP) are controversial. Moreover, no information is available regarding this issue in healthcare-associated pneumonia (HCAP). We aimed to determine the impact of antibiotic timing on 30-day mortality of patients with CAP and HCAP. Non-immunocompromised adults admitted to hospital through the emergency department (ED) with community-onset pneumonia were prospectively observed from 2001 to 2009. Patients who received prior antibiotics were excluded. Of 1593 patients with pneumonia who were analyzed, 1274 had CAP and 319 HCAP. The mean time from patient arrival at the ED until antibiotic administration was 5.8 h (standard deviation (SD) 3.5) in CAP and 6.1 h (SD 3.8) in HCAP (p 0.30). Mortality was higher in patients with HCAP (5.5% vs. 13.5%; p <0.001). After adjusting for confounding factors in a logistic regression analysis, the antibiotic administration £4 h was not associated with decreased 30-day mortality in patients with CAP (odds ratio (OR) 1.12, 95% confidence interval (CI) 0.57-2.21) and in patients with HCAP (OR 0.59, 95% CI 0.19-1.83). Similarly, antibiotic administration £8 h was not associated with decreased 30-day mortality in CAP (OR 1.58, 95% CI 0.64-3.88) and HCAP patients (OR 0.59, 95% CI 0.19-1.83). In conclusion, antibiotic administration within 4 or 8 h of arrival at the ED did not improve 30-day survival in hospitalized adults for CAP or HCAP.
European Journal of Clinical Microbiology & Infectious Diseases, 2009
The time to first antibiotic dose (TFAD) has been mentioned as an important performance indicator in community-acquired pneumonia (CAP). However, the advice to minimise TFAD to 4 hours (4 h) is only based on database studies. We prospectively studied the effect of minimising the TFAD on the early clinical outcome of moderate-severe CAP. On admission, patients' medical data and TFAD were recorded. Early clinical failure was expressed as the proportion of patients with clinical instability, admission to the intensive care unit (ICU) or mortality on day three. Of 166 patients included in the study, 27 patients (29.7%) with TFAD <4 h had early clinical failure compared to 23 patients (37.7%) with TFAD >4 h (odds ratio [OR] 0.69; 95% confidence interval [CI] 0.35-1.35). In multivariate analysis, the pneumonia severity index (OR 1.03; 95%CI 1.01-1.04), confusion (OR 2.63; 95%CI 1.14-6.06), Staphylococcus aureus infection (OR 7.26; 95%CI 1.33-39.69) and multilobar pneumonia (OR 2.40; 95%CI 1.11-5.22) but not TFAD were independently associated with early clinical failure. Clinical parameters on admission other than the TFAD predict early clinical outcome in moderate-severe CAP. In contrast to severe CAP necessitating treatment in the ICU directly, in the case of suspected moderate-severe CAP, there is time to establish a reliable diagnosis of CAP before antibiotics are administered. Therefore, the implementation of the TFAD as a performance indicator is not desirable.
World Journal of Emergency Medicine, 2020
(IDSA) published an evidence-based guideline for the treatment of uncomplicated communityacquired pneumonia (CAP) in children, recommending aminopenicillins as the first-line therapy. Poor guideline compliance with 10%-50% of patients admitted to the hospital receiving narrow-spectrum antibiotics has been reported. A new clinical practice guideline (CPG) was implemented in our emergency department (ED) for uncomplicated CAP. The aim of this study was to examine baseline knowledge and ED provider prescribing patterns pre-and post-CPG implementation. METHODS: Prior to CPG-implementation, an anonymous case-based survey was distributed to evaluate knowledge of the current PIDS/IDSA guideline. A retrospective chart review of patients treated in the ED for CAP from January 2015 to February 2017 was performed to assess prescribing patterns for intravenous (IV) antibiotics in the ED at Children's National Health System pre-and post-CPG implementation. RESULTS: ED providers were aware of the PIDS/IDSA guideline recommendations, with 86.4% of survey responders selecting ampicillin as the initial antibiotic of choice. However, only 41.2% of patients admitted to the hospital with uncomplicated CAP pre-CPG received ampicillin (P<0.01). There was no statistically signifi cant increase in ampicillin prescribing post-CPG (P=0.40). CONCLUSIONS: Providers in the ED are aware of the PIDS/IDSA guideline regarding the first-line therapy for uncomplicated CAP; however, this knowledge does not translate into clinical practice. Implementation of a CPG in isolation did not significantly change prescribing patterns for uncomplicated CAP.