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Adherence to guidelines for hospitalized community-acquired pneumonia over time and its impact on health outcomes and mortality

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Abstract

Compliance with validated guidelines is crucial to guide management of patients hospitalized with community-acquired pneumonia (CAP). Data describing real-life management and treatment of CAP are limited. We aimed to evaluate the compliance with guidelines over time, and to assess its impact on all-cause mortality and clinical outcomes. We retrospectively compared two cohorts of patients admitted to the hospital, throughout 2005, just after the implementation of a local clinical pathway based on CAP international guidelines, and 7 years later over 2012. We included all patients with a diagnosis of pneumonia and/or related complications. 564 patients were included. The Pneumonia Severity Index calculation was better documented in 2012 (25.23 %) compared to 2005 (17.70 %; p = 0.032), but compliance with guideline empirical antibiotic therapy was lower in 2012 (56.70 %) than in 2005 (68.75 %; p = 0.004). Performance of guideline recommended urinary antigen tests was higher in 2012, and associated with 57.3 % lower odds of in-hospital mortality (95 % CI 15.0–78.5 %) and with 65.9 % lower odds of 30-day mortality (95 % CI 31.5–83.0 %). Compliance with empirical antibiotic therapy was associated with 2.9 days lower mean length of hospital stay (95 % CI −4.2 to −1.6 days) and with 2.0 days lower mean duration of antibiotic therapy (95 % CI −3.3 to −0.7 days). Compliance with guidelines changed over time, with some effects on mortality and with an apparent reduction in the length of hospital stay and the duration of antibiotic therapy. Specific clinical training and hospital control policies could achieve greater compliance with guidelines, and thus reduce a burden on hospital services.

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References

  1. Blasi F, Mantero M, Santus P et al (2012) Understanding the burden of pneumococcal disease in adults. Clin Microbiol Infect 18:7–14

    Article  PubMed  Google Scholar 

  2. Ramirez JA, Anzueto AR (2011) Changing needs of community-acquired pneumonia. J Antimicrob Chemother 66:3–9

    Article  Google Scholar 

  3. Welte T, Torres A, Nathwani D (2012) Clinical and economic burden of community-acquired pneumonia among adults in Europe. Thorax 67:71–79

    Article  CAS  PubMed  Google Scholar 

  4. Bauer TT, Welte T, Ernen C et al (2005) Cost analyses of community-acquired pneumonia from the hospital perspective. Chest 128:2238–2246

    Article  PubMed  Google Scholar 

  5. Millett ERC, De Stavola BL, Quint JK et al (2014) Time trends and risk factors for hospitalisation after community-acquired pneumonia in older adults in England. Thorax 69:A10

    Article  Google Scholar 

  6. Blasi F, Garau J, Medina J et al (2013) Current management of patients hospitalized with community-acquired pneumonia across Europe: outcomes from REACH. Respir Res 14:44

    Article  PubMed  PubMed Central  Google Scholar 

  7. Capelastegui A, Espana PP, Quintana JM et al (2004) Improvement of process-of-care and outcomes after implementing a guideline for the management of community-acquired pneumonia: a controlled before-and-after design study. Clin Infect Dis 39:955–963

    Article  PubMed  Google Scholar 

  8. Marrie TJ, Lau CY, Wheeler SL et al (2000) A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-acquired pneumonia intervention trial assessing levofloxacin. JAMA 283:749–755

    Article  CAS  PubMed  Google Scholar 

  9. Blasi F, Iori I, Bulfoni A et al (2008) Can CAP guideline adherence improve patient outcome in internal medicine departments? Eur Resp J 32:902–910

    Article  CAS  Google Scholar 

  10. McCabe C, Kirchner C, Zhang H et al (2009) Guideline-concordant therapy and reduced mortality and length of stay in adults with community-acquired pneumonia. Arch Intern Med 169:1525–1531

    Article  PubMed  Google Scholar 

  11. Uematsu H, Hashimoto H, Iwamoto T et al (2014) Impact of guideline-concordant microbiological testing on outcomes of pneumonia. Int J Qual Health Care 26:100–107

    Article  PubMed  Google Scholar 

  12. Frei CR, Restrepo MI, Mortensen EM et al (2006) Impact of guideline-concordant empiric antibiotic therapy in community-acquired pneumonia. Am J Med 119:865–871

    Article  CAS  PubMed  Google Scholar 

  13. Menéndez R, Reyes S, Martinez R et al (2007) Economic evaluation of adherence to treatment guidelines in nonintensive care pneumonia. Eur Respir J 29:751–756

    Article  PubMed  Google Scholar 

  14. Ostermann H, Garau J, Medina J et al (2014) Resource use by patients hospitalized with community-acquired pneumonia in Europe: analysis of the REACH study. BMC Pulm Med 14:36

    Article  PubMed  PubMed Central  Google Scholar 

  15. Menéndez R, Ferrando D, Vallés JM et al (2002) Influence of deviation from guidelines on the outcome of community-acquired pneumonia. Chest 122:612–617

    Article  PubMed  Google Scholar 

  16. Dean NC, Bateman KA, Donnelly SM et al (2006) Improved clinical outcomes with utilization of a community-acquired pneumonia guideline. Chest 130:794–799

    Article  PubMed  Google Scholar 

  17. Mortensen EM, Restrepo M, Anzueto A et al (2004) Effects of guideline-concordant antimicrobial therapy on mortality among patients with community-acquired pneumonia. Am J Med 117:726–731

    Article  PubMed  Google Scholar 

  18. Menéndez R, Torres A, Zalacaín R et al (2005) Guidelines for the treatment of community-acquired pneumonia: predictors of adherence and outcome. Am J Respir Crit Care Med 172:757–762

    Article  PubMed  Google Scholar 

  19. Dean NC, Silver MP, Bateman KA et al (2001) Decreased mortality after implementation of a treatment guideline for community-acquired pneumonia. Am J Med 110:451–457

    Article  CAS  PubMed  Google Scholar 

  20. Cabana MD, Rand CS, Powe NR et al (1999) Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 282:1458–1465

    Article  CAS  PubMed  Google Scholar 

  21. Woodhead M, Blasi F, Ewig S et al (2011) Guidelines for the management of adult lower respiratory tract infections—full version. Clin Microbiol Infect 17:E1–E59

    Article  PubMed  Google Scholar 

  22. Niederman MS, Mandell LA, Anzueto A et al (2001) American Thoracic Society. Guidelines for the management of adults with Community-Acquired Pneumonia. Am J Respir Crit Care Med 163:1730–1754

    Article  CAS  PubMed  Google Scholar 

  23. British Thoracic Society Standards of Care Committee (2001) BTS guidelines for the management of community acquired pneumonia in adults. Thorax 56:1–58

    Article  Google Scholar 

  24. von Elm E, Altman DG, Egger M et al (2014) The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg 14:S1743–S9191

    Google Scholar 

  25. Ospedale Maggiore della Carità (2014) Standards of service of the Trauma and Orthopaedics ward. Available at: http://www.maggioreosp.novara.it/site/home/attivita-assistenziale/reparti-e-servizi-sanitari/elenco-delle-strutture-sanitarie/documento8021635.html. Accessed 10 Apr 2014

  26. Italian National Institute of Statistics (ISTAT). “Geodemo” demographic data. 2013. Available at: http://demo.istat.it/pop2013/index.html. Accessed 30 Aug 2014

  27. Ewig S (2014) The pneumonia triad. In: Chalmers JD, Pletz MW, Aliberti S (eds) Community-Acquired Pneumonia. Eur Respir Monogr 63:13–24

  28. Mandell LA, Wunderink RG, Anzueto A et al (2007) Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 44:S27–S72

    Article  CAS  PubMed  Google Scholar 

  29. Lim WS, Baudouin SV, George RC et al (2009) British Thoracic Society guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax 64:1–55

    Article  Google Scholar 

  30. Bonaiti G, Aliberti S, Suigo G et al (2013) When do we need to hospitalize a patient with community-acquired pneumonia? Rassegna di Patol dell’Apparato Respir 28:189–195

    Google Scholar 

  31. Dambrava PG, Torres A, Valles X et al (2008) Adherence to guidelines’ empirical antibiotic recommendations and community-acquired pneumonia outcome. Eur Respir J 32:892–901

    Article  CAS  PubMed  Google Scholar 

  32. Carrillo A, Gonzalez-Diaz G, Ferrer M et al (2012) Non-invasive ventilation in community-acquired pneumonia and severe acute respiratory failure. Intensive Care Med 38:458–466

    Article  PubMed  Google Scholar 

  33. Ferrer M, Cosentini R, Nava S (2012) The use of non-invasive ventilation during acute respiratory failure due to pneumonia. Eur J Intern Med 23:420–428

    Article  PubMed  Google Scholar 

  34. Conferenza Stato Regioni (2014) CSR del 5 agosto: definizione degli standard qualitativi, strutturali, tecnologici e quantitativi relativi all’assistenza ospedaliera

  35. Iori I, Gussoni G, Blasi F et al (2008) Guidelines and management of hospitalized patients with community-acquired pneumonia: the Italian experience of the FASTCAP study. Ital J Med 2:5–18

    Google Scholar 

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Acknowledgments

Design of the study: PEB, EC, FP; acquisition of data: EC, EA; interpretation of data: PEB, EC, EA, FP; drafting of the manuscript: PEB, EC, EA, FP; critical revision of the manuscript: PEB, EA, FF, FH.

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Authors and Affiliations

  1. Medical Department, Division of Respiratory Medicine, Ospedale “Maggiore della Carità”, Novara, Italy

    Elisa Costantini, Filippo Patrucco & Piero Emilio Balbo

  2. Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy

    Elisa Costantini, Elias Allara & Fabrizio Faggiano

  3. School of Public Health, University of Torino, Turin, Italy

    Elias Allara

  4. Cardiothoracic Department, Division of Respiratory Medicine, “Città della Salute e della Scienza” Hospital and University of Torino, Turin, Italy

    Filippo Patrucco

  5. Department of Primary Care and Public Health, Imperial College London, London, UK

    Fozia Hamid

  6. Corso Bramante 88/90, 10126, Turin, Italy

    Filippo Patrucco

Authors
  1. Elisa Costantini
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  2. Elias Allara
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  4. Fabrizio Faggiano
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  5. Fozia Hamid
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  6. Piero Emilio Balbo
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Correspondence to Filippo Patrucco.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Costantini, E., Allara, E., Patrucco, F. et al. Adherence to guidelines for hospitalized community-acquired pneumonia over time and its impact on health outcomes and mortality. Intern Emerg Med 11, 929–940 (2016). https://doi.org/10.1007/s11739-016-1445-3

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  • DOI: https://doi.org/10.1007/s11739-016-1445-3

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