During the study period, the recommended empiric regimen for patients admitted to our institution for treatment of community-acquired pneumonia was either combination therapy with IV cefuroxime or ceftriaxone in conjunction with oral or IV azithromycin or monotherapy with oral or IV levofloxacin. The institution’s recommendations for management of community-acquired pneumonia were based on published North American practice guidelines that were current at the time this study was conducted; therefore, the principles of conducting a quality assurance investigation and the observations we obtained may be useful to other Canadian hospitals. The benefits of implementing evidence-based treatment guidelines for patients with community-acquired pneumonia who require hospital admission are well documented.
Mean reported adherence to empiric treatment guidelines for patients admitted to hospital with community-acquired pneumonia ranges from 47% to 97%. At our institution, 56% (33/59) of patients received guideline-recommended empiric therapy, and there was a nonsignificant trend toward increased adherence over the 4-year period of the study. There was no significant difference in the frequency of selection of the 2 guideline-recommended regimens (i.e., fluoroquinolone monotherapy versus second- or third-generation £-lactam plus macrolide combination therapy), and there was no indication that severity of illness dictated the choice of empiric antimicrobial treatment. Halm and others17 found that the use of guideline-recommended antimicrobial therapy increased from 78.1% to 83.4% (p = 0.003) after implementation of a multidisciplinary quality initiative, in which opinion leaders developed evidence-based treatment guidelines and critical pathways, conducted a series of educational lectures with house staff, distributed pocket reminder cards, and promoted standardized orders. After the implementation of institutional guidelines at Sunnybrook in 2002, adherence rates increased steadily, from 50% in 2002 to 64% in 2005; however, the difference over time was not statistically significant.
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Ongoing education of house staff by pharmacists may be an initial effective means to further increase compliance with the treatment guidelines. Twenty-five percent of the patients in this study received appropriate non-guideline-based empiric therapy and 56% received appropriate guideline-based therapy, for a total of 81% (48/59) of patients receiving empiric antibiotic therapy that was assessed as appropriate. The median duration of inappropriate, non-guideline-based therapy was only 24 h, which indicates efficient therapeutic intervention to modify inappropriate therapy. Of the 11 patients who were initially prescribed inappropriate, non-guideline-based antimicrobials, 8 (73%) were switched to an appropriate antimicrobial regimen. The clinical cure rate was greater than 80% for all patients; among those with an initially inappropriate treatment regimen, the cure rate was 82% (9/11), but 8 of these 9 patients were promptly switched to appropriate guideline-based therapy. The objectives of this study did not include evaluating the effectiveness of guideline-based therapy, and the study was therefore not powered to determine any difference in cure rate. For both of these reasons, the absence of a statistically significant difference in cure rate between appropriate and inappropriate therapy is not surprising. However, initial empiric monotherapy with levofloxacin was significantly less expensive than appropriate non- guideline-based therapy, which supports the use of guideline-based therapy rather than appropriate non-guideline-based therapy, provided there is no clinical rationale to deviate from the treatment algorithm.
The all-cause in-hospital mortality rate among these patients was 15% (9/62), and the mortality rate attributable to infection was 10% (6/62). The mortality rate attributable to community-acquired pneumonia in this study is in keeping with the reported attributable mortality rate of 5% to more than 30%.
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