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

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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.

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References

  1. Hall MJ, DeFrances CJ, Williams SN, et al. National Hospital Discharge Survey: 2007 summary. Natl Health Stat Report. 2010;1–20, 24.

  2. Bodenheimer T, Fernandez A. High and rising health care costs. Part 4: can costs be controlled while preserving quality? Ann Intern Med. 2005;143:26–31.

    PubMed  Google Scholar 

  3. Arnold FW, LaJoie AS, Brock GN, et al. Improving outcomes in elderly patients with community-acquired pneumonia by adhering to national guidelines: Community-Acquired Pneumonia Organization International cohort study results. Arch Intern Med. 2009;169:1515–24.

    Article  PubMed  Google Scholar 

  4. Carratala J, Garcia-Vidal C, Ortega L, et al. Effect of a 3-step critical pathway to reduce duration of intravenous antibiotic therapy and length of stay in community-acquired pneumonia: a randomized controlled trial. Arch Intern Med. 2012;172:922–8.

    Article  PubMed  Google Scholar 

  5. Avdic E, Cushinotto LA, Hughes AH, et al. Impact of an antimicrobial stewardship intervention on shortening the duration of therapy for community-acquired pneumonia. Clin Infect Dis. 2012;54:1581–7.

    Article  PubMed  Google Scholar 

  6. Mansouri MD, Cadle RM, Agbahiwe SO, et al. Impact of an antibiotic restriction program on antibiotic utilization in the treatment of community-acquired pneumonia in a Veterans Affairs Medical Center. Infection. 2011;39:53–8.

    Article  PubMed  CAS  Google Scholar 

  7. Marrie TJ, Lau CY, Wheeler SL, et al. A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-acquired pneumonia intervention trial assessing levofloxacin. JAMA. 2000;283:749–55.

    Article  PubMed  CAS  Google Scholar 

  8. Jenkins TC, Sakai J, Knepper BC, et al. Risk factors for drug-resistant Streptococcus pneumoniae and antibiotic prescribing practices in outpatient community-acquired pneumonia. Acad Emerg Med. 2012;19:703–6.

    Article  PubMed  Google Scholar 

  9. Gabow P, Eisert S, Wright R. Denver Health: a model for the integration of a public hospital and community health centers. Ann Intern Med. 2003;138:143–9.

    PubMed  Google Scholar 

  10. The Joint Commission Specifications Manual for National Hospital Inpatient Quality Measures v4.1. Available at: http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx. Accessed 4 Sept 2012.

  11. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44:S27–72.

    Article  PubMed  CAS  Google Scholar 

  12. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:388–416.

    Google Scholar 

  13. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58:377–382

    Article  PubMed  CAS  Google Scholar 

  14. el Moussaoui R, de Borgie CA, van den Broek P, et al. Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderate-severe community acquired pneumonia: randomised, double blind study. BMJ. 2006;332:1355.

    Article  Google Scholar 

  15. McCabe C, Kirchner C, Zhang H, et al. Guideline-concordant therapy and reduced mortality and length of stay in adults with community-acquired pneumonia: playing by the rules. Arch Intern Med. 2009;169:1525–31.

    Article  PubMed  Google Scholar 

  16. Ramirez JA, Vargas S, Ritter GW, et al. Early switch from intravenous to oral antibiotics and early hospital discharge: a prospective observational study of 200 consecutive patients with community-acquired pneumonia. Arch Intern Med. 1999;159:2449–54.

    Article  PubMed  CAS  Google Scholar 

  17. Garcia-Vazquez E, Marcos MA, Mensa J, et al. Assessment of the usefulness of sputum culture for diagnosis of community-acquired pneumonia using the PORT predictive scoring system. Arch Intern Med. 2004;164:1807–11.

    Article  PubMed  Google Scholar 

  18. Sanz F, Restrepo MI, Fernandez E, et al. Hypoxemia adds to the CURB-65 pneumonia severity score in hospitalized patients with mild pneumonia. Respir Care. 2011;56:612–8.

    Article  PubMed  Google Scholar 

  19. Arnold FW, Ramirez JA, McDonald LC, et al. Hospitalization for community-acquired pneumonia: the pneumonia severity index vs clinical judgment. Chest. 2003;124:121–4.

    Article  PubMed  Google Scholar 

  20. Beall DP, Scott WW, Jr., Kuhlman JE, et al. Utilization of computed tomography in patients hospitalized with community-acquired pneumonia. MD Med J. 1998;47:182–7.

    Google Scholar 

  21. Katz DS, Leung AN. Radiology of pneumonia. Clin Chest Med. 1999;20:549–62.

    Article  PubMed  CAS  Google Scholar 

  22. Smith-Bindman R, Lipson J, Marcus R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med. 2009;169:2078–86.

    Article  PubMed  Google Scholar 

  23. Afshar N, Tabas J, Afshar K, et al. Blood cultures for community-acquired pneumonia: are they worthy of two quality measures? A systematic review. J Hosp Med. 2009;4:112–23.

    Article  PubMed  Google Scholar 

  24. Walls RM, Resnick J. The joint commission on accreditation of healthcare organizations and center for medicare and medicaid services community-acquired pneumonia initiative: what went wrong? Ann Emerg Med. 2005;46:409–11.

    Article  PubMed  Google Scholar 

  25. Metersky ML, Ma A, Bratzler DW, et al. Predicting bacteremia in patients with community-acquired pneumonia. Am J Respir Crit Care Med. 2004;169:342–7.

    Article  PubMed  Google Scholar 

  26. Alahmadi YM, Aldeyab MA, McElnay JC, et al. Clinical and economic impact of contaminated blood cultures within the hospital setting. J Hosp Infect. 2011;77:233–6.

    Article  PubMed  CAS  Google Scholar 

  27. Plouffe JF, McNally C, File TM Jr. Value of noninvasive studies in community-acquired pneumonia. Infect Dis Clin North Am. 1998;12:689–99 (ix).

    Article  PubMed  CAS  Google Scholar 

  28. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Prevalence of methicillin-resistant staphylococcus aureus as an etiology of community-acquired pneumonia. Clin Infect Dis. 2012;54:1126–33.

    Article  PubMed  Google Scholar 

  29. Johnson L, Sabel A, Burman WJ, et al. Emergence of fluoroquinolone resistance in outpatient urinary Escherichia coli isolates. Am J Med. 2008;121:876–84.

    Article  PubMed  CAS  Google Scholar 

  30. MacDougall C, Powell JP, Johnson CK, et al. Hospital and community fluoroquinolone use and resistance in Staphylococcus aureus and Escherichia coli in 17 US hospitals. Clin Infect Dis. 2005;41:435–40.

    Article  PubMed  CAS  Google Scholar 

  31. Adam HJ, Hoban DJ, Gin AS, et al. Association between fluoroquinolone usage and a dramatic rise in ciprofloxacin-resistant Streptococcus pneumoniae in Canada, 1997–2006. Int J Antimicrob Agents. 2009;34:82–5.

    Article  PubMed  CAS  Google Scholar 

  32. Stevens V, Dumyati G, Fine LS, et al. Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. Clin Infect Dis. 2011;53:42–8.

    Article  PubMed  Google Scholar 

  33. Kallen AJ, Thompson A, Ristaino P, et al. Complete restriction of fluoroquinolone use to control an outbreak of Clostridium difficile infection at a community hospital. Infect Control Hosp Epidemiol. 2009;30:264–72.

    Article  PubMed  Google Scholar 

  34. Pepin J, Saheb N, Coulombe MA, et al. Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec. Clin Infect Dis. 2005;41:1254–60.

    Article  PubMed  CAS  Google Scholar 

  35. Bernardo J, Yew WW. How are we creating fluoroquinolone-resistant tuberculosis? Am J Respir Crit Care Med. 2009;180:288–9.

    Article  PubMed  Google Scholar 

  36. Chen TC, Lu PL, Lin CY, et al. Fluoroquinolones are associated with delayed treatment and resistance in tuberculosis: a systematic review and meta-analysis. Int J Infect Dis. 2011;15:e211–6.

    Article  PubMed  CAS  Google Scholar 

  37. Zervos M, Mandell LA, Vrooman PS, et al. Comparative efficacies and tolerabilities of intravenous azithromycin plus ceftriaxone and intravenous levofloxacin with step-down oral therapy for hospitalized patients with moderate to severe community-acquired pneumonia. Treat Respir Med. 2004;3:329–36.

    Article  PubMed  CAS  Google Scholar 

  38. Wong-Beringer A, Nguyen LH, Lee M, et al. An antimicrobial stewardship program with a focus on reducing fluoroquinolone overuse. Pharmacotherapy. 2009;29:736–43.

    Article  PubMed  Google Scholar 

  39. Hayashi Y, Paterson DL. Strategies for reduction in duration of antibiotic use in hospitalized patients. Clin Infect Dis. 2011;52:1232–40.

    Article  PubMed  Google Scholar 

  40. Pakyz AL, MacDougall C, Oinonen M, et al. Trends in antibacterial use in US academic health centers: 2002 to 2006. Arch Intern Med. 2008;168:2254–60.

    Article  PubMed  Google Scholar 

  41. Polk RE, Hohmann SF, Medvedev S, et al. Benchmarking risk-adjusted adult antibacterial drug use in 70 US academic medical center hospitals. Clin Infect Dis. 2011;53:1100–10.

    Article  PubMed  Google Scholar 

  42. Norrby SR. Short-term treatment of uncomplicated lower urinary tract infections in women. Rev Infect Dis. 1990;12:458–67.

    Article  PubMed  CAS  Google Scholar 

  43. Woodhead M, Blasi F, Ewig S, et al. Guidelines for the management of adult lower respiratory tract infections—full version. Clin Microbiol Infect. 2011;17:E1–59.

    Article  PubMed  CAS  Google Scholar 

  44. Bartlett JG, Rosenblatt JE, Finegold SM. Percutaneous transtracheal aspiration in the diagnosis of anaerobic pulmonary infection. Ann Intern Med. 1973;79:535–40.

    PubMed  CAS  Google Scholar 

  45. Ries K, Levison ME, Kaye D. Transtracheal aspiration in pulmonary infection. Arch Intern Med. 1974;133:453–8.

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

This work was supported by the Department of Patient Safety and Quality, Denver Health Medical Center. Dr. Jenkins was supported by the National Institute of Allergy and Infectious Diseases (1K23AI099082-01A1).

Conflict of interest

Michael Hanley owns stock in Pfizer and GlaxoSmithKline. All other authors have no conflicts.

Author information

Authors and Affiliations

  1. Department of Medicine, Denver Health Medical Center, 660 Bannock Street, Denver, CO, 80204, USA

    T. C. Jenkins, S. A. Stella, L. Cervantes, C. S. Price, M. E. Hanley, P. S. Mehler & W. J. Burman

  2. Division of Infectious Diseases, Denver Health Medical Center, Denver, CO, USA

    T. C. Jenkins, C. S. Price & W. J. Burman

  3. Department of Patient Safety and Quality, Denver Health Medical Center, Denver, CO, USA

    B. C. Knepper, A. L. Sabel & P. S. Mehler

  4. Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA

    L. Shockley

  5. Division of Pulmonary and Critical Care, Denver Health Medical Center, Denver, CO, USA

    M. E. Hanley

  6. Department of Medicine, University of Colorado Denver, Aurora, CO, USA

    T. C. Jenkins, S. A. Stella, L. Cervantes, C. S. Price, M. E. Hanley, P. S. Mehler & W. J. Burman

  7. Division of Infectious Diseases, University of Colorado Denver, Aurora, CO, USA

    T. C. Jenkins, C. S. Price & W. J. Burman

  8. Department of Emergency Medicine, University of Colorado Denver, Aurora, CO, USA

    L. Shockley

  9. Division of Pulmonary and Critical Care, University of Colorado Denver, Aurora, CO, USA

    M. E. Hanley

  10. Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA

    A. L. Sabel

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  1. T. C. Jenkins
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  2. S. A. Stella
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Correspondence to T. C. Jenkins.

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Jenkins, T.C., Stella, S.A., Cervantes, L. et al. Targets for antibiotic and healthcare resource stewardship in inpatient community-acquired pneumonia: a comparison of management practices with National Guideline Recommendations. Infection 41, 135–144 (2013). https://doi.org/10.1007/s15010-012-0362-2

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  • DOI: https://doi.org/10.1007/s15010-012-0362-2

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