Improved Management of Community-Acquired Pneumonia in the Emergency Department

Cost-Impact Analysis of a Novel Diagnostic Test to Assess Community-Acquired Pneumonia Etiology in the Emergency Department Setting: A Multi-Country European Study

BACKGROUND

We aimed to estimate the economic and clinical impacts of a novel diagnostic test called LIAISON^® MeMed BV^® (LMMBV), which can differentiate bacterial from viral infections, in patients with community-acquired pneumonia (CAP) in emergency departments.

METHODS

A cost-impact simulation model was developed to investigate the financial consequences of the introduction of LMMBV into the standard of care (SOC) diagnostic process in Italy, Germany, and Spain. Clinical outcomes were expressed as antibiotic patients and days saved, reduced hospital admissions, and shortened hospital length of stay (LOS). Cost savings were evaluated from the perspectives of third-party payers and hospitals. A deterministic sensitivity analysis (DSA) was carried out.

RESULTS

LMMBV was associated with a reduction in antibiotic prescriptions, treatment duration, and LOS. Furthermore, the adoption of LMMBV would allow savings per patient up to EUR 364 and EUR 328 for hospitals and EUR 91 and EUR 59 for payers in Italy and Germany, respectively. In Spain, average savings per patient could reach up to EUR 165 for both payers and hospitals. Savings were most sensitive to test accuracy, with DSA confirming the robustness of the results.

CONCLUSIONS

Combining LMMBV with the current SOC diagnostic process is expected to provide clinical and economic benefits in Italy, Germany, and Spain.

Adherence to Guidelines for Assessment and Empiric Antibiotics Recommendations for Community-Acquired Pneumonia at Ambo University Referral Hospital: Prospective Observational Study

OBJECTIVE

The high incidence and substantial morbidity and mortality associated with community-acquired pneumonia necessitate an accurate assessment and appropriate management of patients. This observational prospective study aimed to evaluate the physicians' adherence to the Ethiopian Standard Treatment Guideline for assessment and an empiric antibiotic selection for Community-acquired pneumonia.

RESULTS

The study indicated that the pneumonia severity assessment tool, CURB-65 score, was never used. Of 141 patients referred to an admitting diagnosis of severe community-acquired pneumonia, only 50 were subsequently found to satisfy the guideline criteria, over-diagnosis of 41.9%. Large proportions of the participants (130, 60%) were prescribed antibiotics in the last three months. The most commonly prescribed single antibiotic was Ceftriaxone (47, 21.7%), while ceftriaxone plus azithromycin was the most common combination, 110 (50.7%). In general, the extent of non-adherence to the national guideline for the use of antibiotics was 36.4%. In conclusion, the use of CRB65 scores was uncommon in the study setting. Poor adherence to Ethiopian Standard Treatment Guideline regarding the decision of hospital admission (41.9%) and the antimicrobial selection (36.4%) was determined.

Pharmacist-Driven Implementation of Outpatient Antibiotic Prescribing Algorithms Improves Guideline Adherence in the Emergency Department

Background:

Inappropriate prescribing of antibiotics has been identified as the most important modifiable risk factor for antimicrobial resistance.

Objective:

The purpose of this project was to improve guideline adherence and promote optimal use of outpatient antibiotics in the emergency department (ED).

Methods:

Prescribing algorithms for community-acquired pneumonia (CAP), skin and soft tissue infections (SSTI), and urinary tract infections (UTI) were developed to integrate clinical practice guideline recommendations with local ED antibiogram data. Outcomes were evaluated through chart review of patients prescribed outpatient antibiotics by ED providers. The primary outcome was adherence to clinical practice guidelines, defined as the selection of an appropriate antibiotic agent, dose, and duration of therapy for each patient discharged.

Results:

When compared to patients discharged from the ED prior to algorithm implementation (N = 325), the post-implementation group (N = 353) received more antibiotic prescriptions that were completely guideline adherent (61.5% vs 11.7%, P < .00001). Post-implementation discharge orders demonstrated improvement in the selection of an appropriate agent (87.3% vs 45.5%, P < .00001), dose (91.5% vs 77.2%, P < .00001), and duration of therapy (71.1% vs 39.1%, P < .01). Additionally, fluoroquinolone prescribing rates were reduced (2.3% vs 12.3%, P < .00001). A reduction in all-cause 30-day returns to the ED or urgent care was observed (15.3% vs 21.5%, P = .036).

Conclusion:

Pharmacist-driven implementation of antibiotic prescribing algorithms improved guideline adherence in the outpatient treatment of CAP, SSTI, and UTI.

Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America

Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia.

Methods: A multidisciplinary panel conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations.

Results: The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions.

Conclusions: The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.

Severity scoring systems for pneumonia: current understanding and next steps

PURPOSE OF REVIEW

To describe the current understanding and clinical applicability of severity scoring systems in pneumonia management.

RECENT FINDINGS

Severity scores in community-acquired pneumonia are strong markers of mortality, but are not necessarily clinical decision-aid tools. The use of severity scores to support outpatient care in low-risk patients has moderate-to-strong evidence available in the literature, mainly for the pneumonia severity index, and must be applied together with clinical judgment. It is not clear that severity scores are helpful to guide empiric antibiotic treatment. The inclusion of biomarkers and performance status might improve the predictive performance of the well known severity scores in community-acquired pneumonia. We should improve our methods for score evaluation and move toward the development of decision-aid tools.

SUMMARY

The application of the available evidence favors the use of severity scoring systems to improve the delivery of care for pneumonia patients. The incorporation of new methodologies and the formulation of different questions other than mortality prediction might help the further development of severity scoring systems, and enhance their support to the clinical decision-making process for the pneumonia-management cascade.

Antimicrobial Stewardship in the Emergency Department

The emergency department (ED) is the hub of the US health care system. Acute infectious diseases are frequently encountered in the ED setting, making this a critical setting for antimicrobial stewardship efforts. Systems level and behavioral stewardship interventions have demonstrated success in the ED setting but successful implementation depends on institutional support and the presence of a physician champion. Antimicrobial stewardship efforts in the ED should target high-impact areas: antibiotic prescribing for nonindicated respiratory tract conditions, such as bronchitis and sinusitis; overtreatment of asymptomatic bacteriuria; and using two antibiotics (double coverage) for uncomplicated cases of cellulitis or abscess.

Short-course versus long-course therapy of the same antibiotic for community-acquired pneumonia in adolescent and adult outpatients

BACKGROUND

Community-acquired pneumonia (CAP) is a lung infection that can be acquired during day-to-day activities in the community (not while receiving care in a hospital). Community-acquired pneumonia poses a significant public health burden in terms of mortality, morbidity, and costs. Shorter antibiotic courses for CAP may limit treatment costs and adverse effects, but the optimal duration of antibiotic treatment is uncertain.

OBJECTIVES

To evaluate the efficacy and safety of short-course versus longer-course treatment with the same antibiotic at the same daily dosage for CAP in non-hospitalised adolescents and adults (outpatients). We planned to investigate non-inferiority of short-course versus longer-term course treatment for efficacy outcomes, and superiority of short-course treatment for safety outcomes.

SEARCH METHODS

We searched CENTRAL, which contains the Cochrane Acute Respiratory Infections Group Specialised Register, MEDLINE, Embase, five other databases, and three trials registers on 28 September 2017 together with conference proceedings, reference checking, and contact with experts and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing short- and long-courses of the same antibiotic for CAP in adolescent and adult outpatients.

DATA COLLECTION AND ANALYSIS

We planned to use standard Cochrane methods.

MAIN RESULTS

Our searches identified 5260 records. We did not identify any RCTs that compared short- and longer-courses of the same antibiotic for the treatment of adolescents and adult outpatients with CAP.We excluded two RCTs that compared short courses (five compared to seven days) of the same antibiotic at the same daily dose because they evaluated antibiotics (gemifloxacin and telithromycin) not commonly used in practice for the treatment of CAP. In particular, gemifloxacin is no longer approved for the treatment of mild-to-moderate CAP due to its questionable risk-benefit balance, and reported adverse effects. Moreover, the safety profile of telithromycin is also cause for concern.We found one ongoing study that we will assess for inclusion in future updates of the review.

AUTHORS' CONCLUSIONS

We found no eligible RCTs that studied a short-course of antibiotic compared to a longer-course (with the same antibiotic at the same daily dosage) for CAP in adolescent and adult outpatients. The effects of antibiotic therapy duration for CAP in adolescent and adult outpatients remains unclear.

A Systematic Review of Antimicrobial Stewardship Interventions in the Emergency Department

BACKGROUND/OBJECTIVE

To improve antimicrobial utilization, development and implementation of antimicrobial stewardship programs in the emergency department (ED) has been recommended. The primary objective of this review was to characterize antimicrobial stewardship (AMS) in the ED and to identify interventions that improve patient outcomes or process of care and/or reduce consequences of antimicrobial use.

METHODS

This study was completed as a systematic review. The following databases were searched from inception through November, 2016: MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Scopus, and Web of Science. Randomized controlled trials, nonrandomized controlled trials, controlled and uncontrolled before-and-after studies, interrupted time series studies, and repeated-measures studies evaluating AMS interventions in the ED were included in the review. Studies published in languages other than English were excluded.

RESULTS

A total of 43 studies meeting inclusion criteria were identified from our search. Patient or provider education and guideline or clinical pathway implementation were the most commonly reported interventions. Few studies reported on audit and feedback, and no study evaluated preauthorization. Impact of interventions showed variable results. Where identified, benefits of AMS interventions primarily included improvement in delivery of care or a decrease in antimicrobial utilization; however, most studies were rated as having unclear or high risk of bias.

CONCLUSION

AMS interventions in the ED may improve patient care. However, the optimal combination of interventions is unclear. Additional studies with more rigorous design evaluating core components of AMS programs, including prospective audit and feedback are needed.