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The average length of stay was 14 days (range 2 to 147 days). Patients were treated in hospital with antimicrobial agents for an average of 9 days (range 2 to 36 days). Fifty-nine (95%) of the patients had a change in antimicrobial regimen during the hospital admission (Table 3). The most common reason for a change in therapy was oral step-down of the antimicrobial agents (32/59 or 54%).

Fifteen (24%) of the patients were afebrile through­out the course of the infection (Table 3). For patients who were febrile on admission, the time to defervescence ranged from 1 to 16 days once antibiotics were initiated. Cure of the pneumonia was achieved in 51 (82%) patients. Nine patients (15%) died, 6 (10% of the total sample) as a result of the infection.
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Table 3. Characteristics of Antibiotic Therapy for 62 Patients Treated for Community-Acquired Pneumonia at Sunnybrook Health Sciences Centre between 2002 and 2005


Characteristic of Therapy No.
(%)
of Patients*


Changed during hospital stay (n
= 62)


Yes


59 (95)


No


3 (5)


Rationale for change in therapyt
(n
=


59)


Oral step-down


32 (54)


Clinical improvement


27 (46)


Culture and sensitivity results


25 (42)


To broaden antibiotic coverage


9 (15)


Recommendation of infectious


diseases consultant


8 (14)


Worsening of clinical condition

6 (10)


Antibiotic-associated diarrhea


5 (8)



Stool positive for

Clostridium difficile

toxin


3 (5)


Renal dose adjustment


3 (5)


Suggestion of pharmacist


3 (5)


Concurrent infection


2 (3)


Unknown


5 (8)


Duration of antibiotic therapy (days)t


In hospital


9 (6, 7, 2-36)


Total§


13 (5, 13, 2-36)


Length of hospital stay (days)t


14 (21, 8, 2-147)


Time to defervescence (n
= 62)


Afebrile throughout


15 (24)



< 3


days


28 (45)


4-7 days


12 (19)



> 7


days


7 (11)


*Unless indicated otherwise.


tFor some patients, there was more than one reason for a change


in antibiotic therapy during the hospital stay.


JMean (standard deviation, median, range).


§Includes in-hospital treatment and outpatient treatment after
discharge.

The initial antimicrobial regimen was selected empirically for 59 (95%) of the patients, and 3 (5%) patients received culture-directed antimicrobial therapy (Table 4). The patients whose therapy was directed by culture results received ceftriaxone (1 patient) or either ceftriaxone or ceftazidime combined with ciprofloxacin (2 patients). Thirty-three (56%) of 59 patients received appropriate empiric therapy according to the institu­tion’s guidelines. Adherence to these guidelines for patients admitted during the study period was 50% (11/22) in 2002, 55% (6/11) in 2003, 60% (9/15) in 2004, and 64% (7/11) in 2005 (p = 0.60). The most commonly selected single agent for initial empiric therapy was levofloxacin (15/59 or 25%). All of the patients who received levofloxacin empirically were admitted to the ward rather than to a critical care setting, but 4 (27%) of the 15 should have been admitted to the intensive care unit on the basis of their pneumonia severity index. A second- or third-generation cephalosporin plus a macrolide was the most commonly selected combination therapy used for initial empiric treatment (18/59 or 31%). Cefuroxime was frequently chosen as the empiric cephalosporinin in combination with azithromycin (10/18 or 56%). Appropriate non- guideline-based antibiotics were selected as empiric initial therapy in 25% (15/59) of patients. Therefore, 81% (48/59) of overall empiric antibiotic therapy was assessed as appropriate.
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Table 4. Initial Selection of Antimicrobials for the Management of Community-Acquired Pneumonia in 62 Patients Treated at Sunnybrook Health Sciences Centre between 2002 and 2005



Regimen



No.


(%)

of
Patients



Initial selection (n


= 62)


Empiric


59/62 (95)


Culture-directed


3/62 (5)



Empiric selection of initial therapy (n


= 59)



Monotherapy


17/59 (29)


Fluoroquinolones*


15/59 (25)


Cephalosporin: cefuroxime


1/59 (2)


Aminoglycoside: tobramycin


1/59 (2)



Combination therapy


42/59 (71)


Second- or third-generation
cephalosporin + macrolide


18/59 (31)


Cephalosporin used in combination


Cefuroxime



10/18


(56)


Ceftriaxone



8/18


(44)


Macrolide used in combination


Azithromycin



15/18


(83)


Clarithromycin


3/18 (17)


Fluoroquinolone + B-lactam


4/59 (7)


Fluoroquinolone used in combination


Ciprofloxacin


1/4 (25)


Levofloxacin


3/4 (75)


B-Lactam used in combination


Ceftriaxone


2/4 (50)


Ampicillin


2/4 (50)


Other


20/59 (34)



Empiric antimicrobial management (n


= 59)



Appropriate (either
institutional-based guidelines or appropriate



non-guideline-based therapy)


48/59 (81)


Monotherapy


17/48 (35)


Levofloxacin



15/17


(88)


Other


2/17 (12)


Combination therapy



31/48


(65)


Second- or third-generation
cephalosporin + macrolide


18/31 (58)


Other



13/31


(42)



Inappropriate


11/59 (19)


Patient switched to appropriate
therapy


8/11 (73)


Within 24 h


4/11 (36)


Within 48 h



3/11


(27)


Within 72 h



0/11

(0)


Within 96 h


1/11 (9)


Patient maintained on inappropriate
therapy



3/11


(27)



*Fourteen patients received levofloxacin


500

mg,
and


1


patient received


250

mg
because of renal


impairment.

Eleven (19%) of the 59 patients received non- guideline-based initial empiric therapy that was inappropriate, given their past medical history, initial pneumonia severity, and antibiotic use in the 6 months before hospital admission (Table 4). Three (27%) of these 11 patients continued to receive inappropriate therapy for the entire duration of antimicrobial treatment, but the other 8 (73%) were changed to appropriate therapy (4 [36%] within 24 h, 3 [27%] within 48 h, and 1 [9%] within 96 h). The median duration of inappropriate empiric therapy was 24 h (Table 4). Two (18%) of the 11 patients who received inappropriate non-guideline-based therapy died. One of these patients was switched to appropriate antimicrobial therapy after 48 h and achieved clinical resolution, but a complicated and prolonged course in hospital led to the patient’s death. The second patient was severely ill at the time of presentation, requiring intubation and admission to critical care. The patient was not switched to appropriate antimicrobial therapy, and death, probably secondary to pneumonia, occurred within 2 days of presentation.
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