Clinical and Epidemiological Study

Infection

, Volume 41, Issue 1, pp 135-144

First online:

Targets for antibiotic and healthcare resource stewardship in inpatient community-acquired pneumonia: a comparison of management practices with National Guideline Recommendations

  • T. C. JenkinsAffiliated withDepartment of Medicine, Denver Health Medical CenterDivision of Infectious Diseases, Denver Health Medical CenterDepartment of Medicine, University of Colorado DenverDivision of Infectious Diseases, University of Colorado Denver Email author 
  • , S. A. StellaAffiliated withDepartment of Medicine, Denver Health Medical CenterDepartment of Medicine, University of Colorado Denver
  • , L. CervantesAffiliated withDepartment of Medicine, Denver Health Medical CenterDepartment of Medicine, University of Colorado Denver
  • , B. C. KnepperAffiliated withDepartment of Patient Safety and Quality, Denver Health Medical Center
  • , A. L. SabelAffiliated withDepartment of Patient Safety and Quality, Denver Health Medical CenterDepartment of Biostatistics and Informatics, Colorado School of Public Health
  • , C. S. PriceAffiliated withDepartment of Medicine, Denver Health Medical CenterDivision of Infectious Diseases, Denver Health Medical CenterDepartment of Medicine, University of Colorado DenverDivision of Infectious Diseases, University of Colorado Denver
  • , L. ShockleyAffiliated withDepartment of Emergency Medicine, Denver Health Medical CenterDepartment of Emergency Medicine, University of Colorado Denver
  • , M. E. HanleyAffiliated withDepartment of Medicine, Denver Health Medical CenterDivision of Pulmonary and Critical Care, Denver Health Medical CenterDepartment of Medicine, University of Colorado DenverDivision of Pulmonary and Critical Care, University of Colorado Denver
  • , P. S. MehlerAffiliated withDepartment of Medicine, Denver Health Medical CenterDepartment of Patient Safety and Quality, Denver Health Medical CenterDepartment of Medicine, University of Colorado Denver
    • , W. J. BurmanAffiliated withDepartment of Medicine, Denver Health Medical CenterDivision of Infectious Diseases, Denver Health Medical CenterDepartment of Medicine, University of Colorado DenverDivision of Infectious Diseases, University of Colorado Denver

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Abstract

Purpose

Community-acquired pneumonia (CAP) is the most common infection leading to hospitalization in the USA. The objective of this study was to evaluate management practices for inpatient CAP in relation to Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guidelines to identify opportunities for antibiotic and health care resource stewardship.

Methods

This was a retrospective cohort study of adults hospitalized for CAP at a single institution from 15 April 2008 to 31 May 2009.

Results

Of the 209 patients with CAP who presented to Denver Health Medical Center during the study period and were hospitalized, 166 (79 %) and 43 (21 %) were admitted to a medical ward and the intensive care unit (ICU), respectively. Sixty-one (29 %) patients were candidates for outpatient therapy per IDSA/ATS guidance with a CURB-65 score of 0 or 1 and absence of hypoxemia. Sputum cultures were ordered for 110 specimens; however, an evaluable sample was obtained in only 49 (45 %) cases. Median time from antibiotic initiation to specimen collection was 11 [interquartile range (IQR) 6–19] h, and a potential pathogen was identified in only 18 (16 %) cultures. Blood cultures were routinely obtained for both non-ICU (81 %) and ICU (95 %) cases, but 15 of 36 (42 %) positive cultures were false-positive results. The most common antibiotic regimen was ceftriaxone + azithromycin (182, 87 % cases). Discordant with IDSA/ATS recommendations, oral step-down therapy consisted of a new antibiotic class in 120 (66 %), most commonly levofloxacin (101, 55 %). Treatment durations were typically longer than suggested with a median of 10 (IQR 8–12) days.

Conclusions

In this cohort of patients hospitalized for CAP, management was frequently inconsistent with IDSA/ATS guideline recommendations, revealing potential targets to reduce unnecessary antibiotic and healthcare resource utilization.

Keywords

Pneumonia Community-acquired pneumonia Guidelines Infectious Diseases Society of America Antimicrobial stewardship Streptococcus pneumoniae Fluoroquinolones