Getting Physicians to Make “The Switch”: The Role of Clinical Guidelines in the Management of Community-Acquired Pneumonia

Exclusive oral antibiotic treatment for hospitalized community-acquired pneumonia: a post-hoc analysis of a randomized clinical trial

OBJECTIVES

In this study, we aimed to assess the efficacy of different ways of administration and types of beta-lactams for hospitalized community-acquired pneumonia (CAP).

METHODS

In this post-hoc analysis of randomized controlled trials (RCT) on patients hospitalized for CAP (pneumonia short treatment trial) comparing 3-day vs. 8-day durations of beta-lactams, which concluded to non-inferiority, we included patients who received either amoxicillin-clavulanate (AMC) or third-generation cephalosporin (3GC) regimens, and exclusively either intravenous or oral treatment for the first 3 days (followed by either 5 days of oral placebo or AMC according to randomization). The choice of route and molecule was left to the physician in charge. The main outcome was a failure at 15 days after the first antibiotic intake, defined as temperature >37.9°C, and/or absence of resolution/improvement of respiratory symptoms, and/or additional antibiotic treatment for any cause. The primary outcome according to the route of administration was evaluated through logistic regression. Inverse probability treatment weighting with a propensity score model was used to adjust for non-randomization of treatment routes and potential confounders. The difference in failure rates was also evaluated among several sub-populations (AMC vs. 3GC treatments, intravenous vs. oral AMC, patients with multi-lobar infection, patients aged ≥65 years old, and patients with CURB65 scores of 3-4).

RESULTS

We included 200 patients from the original trial, with 93/200 (46.5%) patients only treated with intravenous treatment and 107/200 (53.5%) patients only treated with oral therapy. The failure rate at Day 15 was not significantly different among patients treated with initial intravenous vs. oral treatment [25/93 (26.9%) vs. 28/107 (26.2%), adjusted odds ratios (aOR) 0.973 (95% CI 0.519-1.823), p 0.932)]. Failure rates at Day 15 were not significantly different among the subgroup populations.

DISCUSSION

Among hospitalized patients with CAP, there was no significant difference in efficacy between initial intravenous and exclusive oral treatment.

TRIAL REGISTRATION

This trial is registered with ClinicalTrials.gov, NCT01963442.

Effects of Hospital Practice Patterns for Antibiotic Administration for Pneumonia on Hospital Lengths of Stay and Costs

BACKGROUND

Hospital practice patterns vary for switching from intravenous to oral antibiotics for community-acquired pneumonia in pediatric patients, but it is unknown how these practice patterns affect hospital lengths of stay and costs.

METHODS

We conducted a retrospective study of 78673 pediatric patients (aged 3 months to 17 years) hospitalized for community-acquired pneumonia. Analyses were performed with data from the Pediatric Health Information System between 2007 and 2016, including discharge data from 48 freestanding children's hospitals. Patients who received antibiotics used to treat aspiration pneumonia and patients with a complex chronic condition were excluded to focus the study on uncomplicated cases. We modeled hospital practice patterns using hospital-level averages for the last day of service on which patients received antibiotics intravenously or first day of service on which patients received antibiotics orally.

RESULTS

We found that a 1-day decrease in the hospital-level average last day of service on which a patient received antibiotics intravenously reduced the average length of stay by 0.58 day (95% confidence interval [CI], -0.69 to -0.47 day) and average cost by $1332 (95% CI, -$2363 to -$300). Results were similar when hospital practice patterns were modeled using the average first day of service on which a patient received antibiotics orally. These reductions in lengths of stay and costs were not associated with a difference in 30-day readmission rates.

CONCLUSIONS

Given the reductions in lengths of stay and costs without sacrificing patient outcomes (readmissions), antimicrobial stewardship programs could target provider education on the duration of intravenous antibiotic therapy as a way to reduce resource utilization.

[Guidelines for the probabilistic treatment of community-acquired pneumonia: compared experience between internal medicine and emergency departments in the University Hospital of Besançon, France]

INTRODUCTION

The objective of this study was to assess the application of local and national recommendations in the management of community-acquired pneumonia in an internal medicine department with an antibiotic referent physician and in an emergency department.

PATIENTS AND METHODS

This was a retrospective single-center study including patients admitted with community-acquired pneumonia in the internal medicine department of the University Hospital of Besançon after an initial admission in the emergency department.

RESULTS

One hundred patients (58 women and 42 men) were included. The mean age was 79 ± 11 years. The prescriptions done in the emergency department were in accordance with local recommendations or Société de pathologie infectieuse de langue française (SPILF) recommendations in 62% of cases. The prescriptions followed the recommendations in 94% of cases in internal medicine department (P<0.05). The lack of initial antibiotic treatment had no influence on morbidity and mortality.

CONCLUSION

The guidelines for infectious diseases treatment were significantly more often applied in a department where a referent physician was designated for this.

Should management of pneumonia be an indicator of quality of care?

Many regulatory bodies and payers measure the quality of care provided to patients admitted to the hospital with pneumonia. Some pneumonia quality measures were not based on high-level evidence, and there is also concern that public reporting of performance could drive excessive use of diagnostic testing and antibiotic treatment. There have been significant increases in the performance rate of several process of care recommended for patients hospitalized with pneumonia, accompanied by a decrease in 30-day mortality. To maximize the potential for improved patient outcomes, physicians and regulators must remain vigilant to detect unintended negative consequences related to performance measurement.

Application of antimicrobial stewardship to optimise management of community acquired pneumonia

The aim of this study was to review the application of antimicrobial stewardship principles to the management of community-acquired pneumonia (CAP). Data from 14 published clinical studies, meta-analyses and practice guidelines regarding the application of antimicrobial stewardship strategies to the management of CAP were identified and analysed. In the context of CAP, application of stewardship strategies (alone or in combination) has been shown to increase physician awareness of guidelines, improve appropriate antimicrobial use and reduce unnecessary antimicrobial prescribing. In addition, application has had a profound favourable impact on patient outcomes, including decreased 30-day mortality and in-hospital mortality rates, reduced length of hospital stay, reduced treatment failure rates and reduced healthcare costs. Antimicrobial stewardship programmes have been demonstrated to successfully increase the level of appropriate antibiotic prescribing, reduce pathogen resistance and improve clinical outcomes in the management of CAP within hospitals. Studies have also shown that adherence to evidence-based guidelines, even at the level of the individual clinician, can have a profound and positive impact on patient outcomes and healthcare costs. Adherence to evidence-based guidelines can have a profound and positive impact on patient outcomes and healthcare costs.

Early switch to oral versus intravenous antimicrobial treatment for hospitalized patients with acute pyelonephritis: a systematic review of randomized controlled trials

BACKGROUND

Acute pyelonephritis is a common infection with significant morbidity and mortality, particularly in pediatric populations. Early-switch strategies (from intravenous to oral treatment) may be an acceptable or even preferred option in the treatment of patients with acute pyelonephritis in terms of effectiveness and safety and can also reduce the economical burden associated with pyelonephritis.

OBJECTIVE

We sought to evaluate the effectiveness and safety of early-switch strategies in hospitalized patients with acute uncomplicated pyelonephritis.

METHODS

We searched in PubMed, Cochrane Central Register of Controlled Trials, and Scopus to identify randomized controlled trials (RCTs) that compared intravenous antibiotic regimens to regimens including an early switch to oral (after initial intravenous) treatment.

RESULTS

Eight RCTs (6 in children) were eligible for inclusion. In 5 RCTs the intravenous antibiotic treatment arms were not switched to oral treatment until the end of the study while in the remaining 3 RCTs the intravenous arms were switched late to oral treatment (after 5-10 days). Data regarding the incidence of renal scars, microbiological eradication, clinical cure, reinfection, persistence of acute pyelonephritis, and adverse events were provided in 4 (all pediatric trials), 6 (4 pediatric), 4 (2 pediatric), 5 (3 pediatric), 3 (1 pediatric), and 5 RCTs (3 pediatric), respectively. There were no differences regarding the above outcomes between the two compared treatment regimens in either pediatric or adult populations.

CONCLUSION

Early switch to oral antibiotic strategies seem to be as effective and safe as intravenous regimens for the treatment of hospitalized patients with acute pyelonephritis. These findings suggest that there is probably a potential to decrease the duration of intravenous treatment by 4-11 days in hospitalized patients with acute pyelonephritis without compromising their outcomes.

Implementing a hospital guideline on pneumonia: a semi-quantitative review

BACKGROUND AND OBJECTIVE

To quantify the impact of different guideline implementation interventions to improve treatment of community-acquired pneumonia (CAP) in a hospital setting.

METHODS

Pubmed, the Cochrane Library, the Cochrane Effective Practice and Organization of Care specialized register, EMBASE and CINAHL.

STUDY SELECTION

Hospital-based trials studying the effect of guidelines on compliance with care processes, clinical and/or economic outcomes in the treatment of CAP together with a description of their implementation interventions.

DATA EXTRACTION

Two independent reviewers extracted and categorized utilized implementation interventions, assessed intensity of use and calculated changes for process of care variables, clinical and economical outcomes. Correlations between interventions and improvement of outcomes were assessed by means of Spearman's rho-test and Mann-Whitney U-test.

RESULTS

In 27 included studies, educational meetings (21/27) and distribution of written material (14/27) were the two most used interventions. Most individual studies show positive overall results, but taken together, no significant relation between number or type of implementation interventions and improvement of outcomes could be detected. Only audit and feedback showed a significant negative influence on the improvement rate of length of stay (p = 0.003; n = 20).

CONCLUSION

Other hospital-specific factors are likely to have a higher impact on the rate of improvement than the implementation interventions alone. Describing which interventions are most successful is unlikely to be correct without taking these hospital-specific factors into account. Future research should focus on how to identify and define these factors and how to adapt the intervention to hospital-specific factors.

Early switch to oral antibiotics and early discharge guidelines in the management of community-acquired pneumonia

BACKGROUND AND OBJECTIVE

The major cost of managing community-acquired pneumonia (CAP) relates to the duration i.v. antibiotic use and length of hospital stay (LOS). Guidelines on early switch to oral antibiotics and early discharge from hospital may help to achieve a unified approach to managing CAP. The aim of this study was to assess the benefits and safety of these guidelines in an Australian respiratory medicine unit.

METHODS

This prospective study included consecutive patients admitted with a diagnosis of CAP over a 6-month period. Early switch to oral antibiotics and early discharge guidelines were implemented one month prior to the evaluation period. Comparison was made to a retrospective control group admitted before the guidelines were implemented. Data collection included patient demographics, clinical and outcome parameters, duration of i.v. antibiotics and LOS. Thirty-day outcomes on patient safety and satisfaction were collected from the prospective group.

RESULTS

One hundred and twenty-five patients in the prospective group were compared to 100 patients in the controls. Baseline characteristics were similar between the comparison groups. Both the mean duration of i.v. antibiotics used (3.38 +/- 0.22 vs. 3.99 +/- 0.28 days, P = 0.03) and LOS (7.62 +/- 0.60 vs. 8.36 +/- 0.55 days, P = 0.04) were significantly shorter in the prospective group. Thirty-day readmission rate was 6% and patient self-reported overall satisfaction was 93.9% in those who were followed up.

CONCLUSIONS

The use of early switch and early discharge guidelines for CAP reduced the duration of i.v. antibiotics and LOS while maintaining high levels of safety and patient satisfaction.

Do Educational Interventions Improve Management of Patients with Community-Acquired Pneumonia?

Community-acquired pneumonia (CAP) is the Leading cause of death from infection. In order to evaluate physicians' adherence to hospital guidelines for CAP, an observational prospective study during two consecutive winter periods at an Irish teaching hospital was performed. A series of educational sessions on management of CAP was provided for medical staff at the end of the first year. Comparison of results showed significant improvement in the rate of blood culture sampling (p < .01), sputum sampling (p < .05), and combined blood culture and sputum sampling (p < .01). Length of antibiotic treatment was more appropriate in the second study year. Results indicate that antibiotic audit and educational interventions improve physicians' adherence to hospital guidelines.