Community-acquired pneumonia is defined as an acute infection of the pulmonary parenchyma occurring in patients residing outside of a hospital or in patients who have been living in a long-term care facility for longer than 2 weeks. This disease is a leading cause of morbidity and mortality in Canada. In 2001, pneumonia and influenza together represented the seventh leading cause of death in the United States. In that country, the annual incidence of community-acquired pneumonia is 12 to 18 cases per 1000 population, resulting in 600 000 to 1 million admissions to hospital and an estimated 40 000 to 60 000 deaths per year. Because of comorbidities, elderly people account for the majority of admissions and deaths. Approximately 80% of infected patients are treated as outpatients, with the remaining 20% requiring admission to hospital. Depending on the presence of comorbid conditions, mortality rates associated with community-acquired pneumonia range from 1% to 30%, and in-hospital mortality has been reported to range from 5% to more than 30%. The overall economic impact of community-acquired pneumonia in the United States is estimated at US$8 billion. Canadian hospital admissions, deaths, and costs may be estimated by applying a factor of 0.1 (10%) to these US population-based data. Because of the substantial mortality and morbidity, as well as the high incidence, community-acquired pneumonia remains a serious health issue for patients and society as a whole.
The etiology of community-acquired pneumonia is often unknown, and a pathogen is recovered in only 40% to 60% of all cases. The most common pathogen found among patients requiring hospital admission is Streptococcus pneumoniae (17.3%), followed by Mycoplasma pneumoniae (13.7%), Chlamydia pneumoniae (10.1%), Hemophilus influenzae (6.6%), aerobic gram-negative bacilli (4.0%), Staphylococcus aureus (2.9%), and Legionella pneumophila (1.3%). Multiple pathogens have been identified in 2% to 11% and even up to 30%8 of cases. The spectrum of potential pathogens in a particular case may be predicted by factors such as age, severity of the pneumonia, comorbidities, clinical risk factors, and community location (residential home versus nursing home). levitra plus
The mortality rate is higher if the initial antimicrobial treatment is inappropriate. However, as noted above, the disease can be caused by a number of organisms. The causative organism cannot be identified by clinical and radiologic findings, and conventional microbiological findings lack sensitivity and specificity, yet it has been shown that shorter time to diagnosis and treatment initiation results in a better prognosis. Therefore, therapy is selected empirically at the time of diagnosis. The development of evidence-based guidelines for community-acquired pneumonia has assisted physicians in the selection of antibiotics and has reduced variability in clinical care. The implementation of guidelines has led to shorter duration of total antibiotic treatment, fewer days on IV antibiotics, lower costs, and assurance of better coverage for atypical bacteria. Adherence to evidence-based guidelines has been shown to decrease the number of hospital admissions, shorten the length of stay in hospital, and reduce the mortality rate.
Recommendations for the treatment of community- acquired pneumonia in patients requiring admission to Sunnybrook Health Sciences Centre (known at the time as the Sunnybrook campus of Sunnybrook and Women’s College Health Sciences Centre) were approved by the Medical Advisory Committee and implemented in January 2002. These recommendations were based on published guidelines that were available in 2002 and that were not updated or replaced by other guidelines up to and including 2006. Specifically, the approved guidelines at our hospital included IV use of either cefuroxime or ceftriaxone in conjunction with oral or IV azithromycin or monotherapy with oral or IV levofloxacin. Data on the frequency of selection of each management strategy, the cost associated with the use of each strategy, the clinical outcome, and microbiological data about the patient population were lacking. A quality assurance study to collect this type of information was important to determine whether reassessment of current recommendations was necessary to optimize patient care, in the absence of any update to published, evidence-based treatment guidelines from 2002 through 2006.
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Therefore, given that adherence to evidence-based guidelines for community-acquired pneumonia is beneficial, the objectives of this study were to determine whether the evidence-based treatment guideline adopted by Sunnybrook Health Sciences Centre was being followed, to identify the current therapeutic approach (or approaches) to managing patients with community-acquired pneumonia at this hospital, and to determine the need for revision of current institutional guidelines, according to clinical outcome and patterns of microbiological culture and sensitivity data, in the absence of updates to published guidelines at the time the study was undertaken.