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Catton T, Umpleby H, Dushianthan A, Saeed K. Provision of Microbiology, Infection Services and Antimicrobial Stewardship in Intensive Care: A Survey across the Critical Care Networks in England and Wales. Antibiotics (Basel) 2023; 12:antibiotics12040768. [PMID: 37107130 PMCID: PMC10135214 DOI: 10.3390/antibiotics12040768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
Infection rounds in Intensive Care Units (ICU) can impact antimicrobial stewardship (AMS). The aim of this survey was to assess the availability of microbiology, infection, AMS services, and antimicrobial prescribing practices in the UK ICUs. An online questionnaire was sent to clinical leads for ICUs in each region listed in the Critical Care Network for the UK. Out of 217 ICUs, 87 deduplicated responses from England and Wales were analyzed. Three-quarters of those who responded had a dedicated microbiologist, and 50% had a dedicated infection control prevention nurse. Infection rounds varied in their frequency, with 10% providing phone advice only. Antibiotic guidance was available in 99% of the units; only 8% of those were ICU-specific. There were variations in the availability of biomarkers & the duration of antibiotics prescribed for pneumonia (community, hospital, or ventilator), urinary, intra-abdominal, and line infections/sepsis. Antibiotic consumption data were not routinely discussed in a multi-disciplinary meeting. The electronic prescription was available in ~60% and local antibiotic surveillance data in only 47% of ICUs. The survey highlights variations in practice and AMS services and may offer the opportunity to further collaborations and share learnings to support the safe use of antimicrobials in the ICU.
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Affiliation(s)
- Tim Catton
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK
| | - Helen Umpleby
- Department of Infection, Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital, Romsey Road, Winchester SO22 5DG, UK
| | - Ahilanandan Dushianthan
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK
- NIHR Southampton Clinical Research Facility and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, and the University of Southampton, Tremona Road, Southampton SO16 6YD, UK
- Faculty of Medicine, University of Southampton, Tremona Road, Southampton SO16 6YD, UK
| | - Kordo Saeed
- Faculty of Medicine, University of Southampton, Tremona Road, Southampton SO16 6YD, UK
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK
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Kruckow KL, Zhao K, Bowdish DME, Orihuela CJ. Acute organ injury and long-term sequelae of severe pneumococcal infections. Pneumonia (Nathan) 2023; 15:5. [PMID: 36870980 PMCID: PMC9985869 DOI: 10.1186/s41479-023-00110-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 01/31/2023] [Indexed: 03/06/2023] Open
Abstract
Streptococcus pneumoniae (Spn) is a major public health problem, as it is a main cause of otitis media, community-acquired pneumonia, bacteremia, sepsis, and meningitis. Acute episodes of pneumococcal disease have been demonstrated to cause organ damage with lingering negative consequences. Cytotoxic products released by the bacterium, biomechanical and physiological stress resulting from infection, and the corresponding inflammatory response together contribute to organ damage accrued during infection. The collective result of this damage can be acutely life-threatening, but among survivors, it also contributes to the long-lasting sequelae of pneumococcal disease. These include the development of new morbidities or exacerbation of pre-existing conditions such as COPD, heart disease, and neurological impairments. Currently, pneumonia is ranked as the 9th leading cause of death, but this estimate only considers short-term mortality and likely underestimates the true long-term impact of disease. Herein, we review the data that indicates damage incurred during acute pneumococcal infection can result in long-term sequelae which reduces quality of life and life expectancy among pneumococcal disease survivors.
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Affiliation(s)
- Katherine L Kruckow
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kevin Zhao
- McMaster Immunology Research Centre and the Firestone Institute for Respiratory Health, McMaster University, Hamilton, Canada
| | - Dawn M E Bowdish
- McMaster Immunology Research Centre and the Firestone Institute for Respiratory Health, McMaster University, Hamilton, Canada
| | - Carlos J Orihuela
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, USA.
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Trent SA, Jarou ZJ, Havranek EP, Ginde AA, Haukoos JS. Variation in Emergency Department Adherence to Treatment Guidelines for Inpatient Pneumonia and Sepsis: A Retrospective Cohort Study. Acad Emerg Med 2019; 26:908-920. [PMID: 30343515 DOI: 10.1111/acem.13639] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/12/2018] [Accepted: 10/17/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Evidence-based clinical practice guidelines (CPGs) for the treatment of pneumonia and sepsis have existed for many years with multiple studies suggesting improved patient outcomes. Despite their importance, little is known about variation in emergency department (ED) adherence to these CPGs. Our objectives were to estimate variation in ED adherence across CPGs for pneumonia and sepsis and identify patient, provider, and environmental factors associated with adherence. METHODS This was a multicenter retrospective study using standard medical record review methods. The population consisted of consecutive adults hospitalized for pneumonia or sepsis (identified by discharge ICD-9 codes) at five Colorado hospitals (two academic, three community) who were admitted to the hospital from the ED and for whom the ED diagnosed or initiated treatment. The outcome measured was ED adherence to the CPG (primary) and in-hospital mortality (secondary). Hierarchical generalized linear models were used for analysis. RESULTS Among 827 patients, ED care was 57% adherence to CPGs with significant variation in adherence across CPGs (sepsis 50%, pneumonia 64%, p < 0.001). Patients were less likely to receive adherent care if they presented with chief complaints that were associated but not typical of the diagnosis (odds ratio [OR] = 0.6, 95% confidence interval [CI] = 0.4-0.8), received an ED diagnosis that was not specific to the CPG (associated diagnosis OR = 0.3 [95% CI = 0.2-0.5]; unrelated diagnosis OR = 0.4 [95% CI = 0.2-0.6]) or presented to a community hospital (OR = 0.6, 95% CI = 0.4-0.9). ED CPG nonadherence was associated with higher in-hospital mortality (OR = 2.4, 95% CI = 1.2-4.8). CONCLUSION Adherence to ED infectious CPGs for pneumonia and sepsis varies significantly across diseases and types of institutions with significant room for improvement, especially in light of a significant association with in-hospital mortality.
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Affiliation(s)
- Stacy A. Trent
- Department of Emergency Medicine Denver Health Medical Center Denver CO
- Department of Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Zachary J. Jarou
- Department of Emergency Medicine Denver Health Medical Center Denver CO
- Department of Emergency Medicine University of Chicago School of Medicine Chicago IL
| | - Edward P. Havranek
- Department of Medicine Denver Health Medical Center Denver CO
- Division of Cardiology University of Colorado School of Medicine Aurora CO
| | - Adit A. Ginde
- Department of Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Jason S. Haukoos
- Department of Emergency Medicine Denver Health Medical Center Denver CO
- Department of Emergency Medicine University of Colorado School of Medicine Aurora CO
- Department of Epidemiology Colorado School of Public Health Aurora CO
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Boots RJ, Lipman J, Bellomo R, Stephens D, Heller RF. Disease Risk and Mortality Prediction in Intensive Care Patients with Pneumonia. Australian and New Zealand Practice in Intensive Care (ANZPIC II). Anaesth Intensive Care 2019; 33:101-11. [PMID: 15957699 DOI: 10.1177/0310057x0503300116] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study of ventilated patients investigated pneumonia risk factors and outcome predictors in 476 episodes of pneumonia (48% community-acquired pneumonia, 24% hospital-acquired pneumonia, 28% ventilator-associated pneumonia) using a prospective survey in 14 intensive care units within Australia and New Zealand. For community acquired pneumonia, mortality increased with immunosuppression (OR 5.32, CI 95% 1.58–17.99, P<0.01), clinical signs of consolidation (OR 2.43, CI 95% 1.09–5.44, P=0.03) and Sepsis-Related Organ Failure Assessment (SOFA) scores (OR 1.19, CI 95% 1.08–1.30, P<0.001) but improved if appropriate antibiotic changes were made within three days of intensive care unit admission (OR 0.42, CI 95% 0.20–0.86, P=0.02). For hospital-acquired pneumonia, immunosuppression (OR 6.98, CI 95% 1.16–42.2, P=0.03) and non-metastatic cancer (OR 3.78, CI 95% 1.20–11.93, P=0.02) were the principal mortality predictors. Alcoholism (OR 7.80, CI 95% 1.20–17.50, P<0.001), high SOFA scores (OR 1.44, CI 95% 1.20–1.75, P=0.001) and the isolation of “high risk” organisms including Pseudomonas aeruginosa, Acinetobacter spp, Stenotrophomonas spp and methicillin resistant Staphylococcus aureus (OR 4.79, CI 95% 1.43–16.03, P=0.01), were associated with increased mortality in ventilator-associated pneumonia. The use of non-invasive ventilation was independently protective against mortality for patients with community-acquired and hospital-acquired pneumonia (OR 0.35, CI 95% 0.18–0.68, P=0.002). Mortality was similar for patients requiring both invasive and non-invasive ventilation and non-invasive ventilation alone (21% compared with 20% respectively, P=0.56). Pneumonia risks and mortality predictors in Australian and New Zealand ICUs vary with pneumonia type. A history of alcoholism is a major risk factor for mortality in ventilator-associated pneumonia, greater in magnitude than the mortality effect of immunosuppression in hospital-acquired pneumonia or community-acquired pneumonia. Non-invasive ventilation is associated with reduced ICU mortality. Clinical signs of consolidation worsen, while rationalising antibiotic therapy within three days of ICU admission improves mortality for community-acquired pneumonia patients.
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Affiliation(s)
- R J Boots
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia
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Vardakas KZ, Trigkidis KK, Apiranthiti KN, Falagas ME. The dilemma of monotherapy or combination therapy in community-acquired pneumonia. Eur J Clin Invest 2017; 47. [PMID: 29027205 DOI: 10.1111/eci.12845] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 10/09/2017] [Indexed: 11/26/2022]
Abstract
SCOPE To study the factors associated with mortality in hospitalized patients with community-acquired pneumonia treated with monotherapy or combination therapy. METHODS PubMed and Scopus were searched. Patients receiving macrolides, β-lactams and fluoroquinolones, as monotherapy or in combination, were included. Meta-analyses and meta-regressions were performed. RESULTS Fifty studies were included. Overall, monotherapy was not associated with higher mortality than combination (RR 1.14, 95% CI 0.99-1.32, I2 84%). Monotherapy was associated with higher mortality than combination in North American and retrospective studies. β-lactam monotherapy was associated with higher mortality than β-lactam/macrolide combination in the primary (1.32, 1.12-1.56, I2 85%) and most sensitivity analyses. There was no difference in mortality between fluoroquinolone monotherapy and β-lactam/macrolide combination (0.98, 0.78-1.23, I2 73%). In meta-regressions, the moderators that could partially explain the observed statistical heterogeneity were the frequency of cancer patients (P = .03) and Pneumonia Severity Index score IV (P = .008). CONCLUSION Due to the considerable heterogeneity and inclusion of unadjusted data, it is difficult to recommend a specific antibiotic regimen over another. Specific antibiotic regimens, study design and the characteristics of the population under study seem to influence the reported outcomes.
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Affiliation(s)
- Konstantinos Z Vardakas
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece.,Department of Medicine, Henry Dunant Hospital Center, Athens, Greece
| | - Kyriakos K Trigkidis
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece.,Department of Internal Medicine, Evangelismos General Hospital, Athens, Greece
| | - Katerina N Apiranthiti
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece.,Department of Internal Medicine, Evangelismos General Hospital, Athens, Greece
| | - Matthew E Falagas
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece.,Department of Medicine, Henry Dunant Hospital Center, Athens, Greece.,Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
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Fahs I, Shrayteh Z, Abdulkhalek R, Salameh P, Hallit S, Malaeb D. Professional practice evaluation of emergency department prescriptions for community-acquired infections in Lebanon. Int J Infect Dis 2017; 64:74-79. [PMID: 28941632 DOI: 10.1016/j.ijid.2017.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 09/02/2017] [Accepted: 09/05/2017] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Selecting the appropriate antibiotic regimen is extremely important in improving patient outcomes, minimizing antimicrobial resistance, and reducing costs. This study was conducted to evaluate current prescribing practices for empiric antibiotics at the time of admission to the emergency department (ED) and to assess their appropriateness in Lebanon. METHODS A retrospective observational study was conducted at three different Lebanese hospitals between June and December 2016. Adult patients who received antibiotics in the ED during the study period were included. The assessment of antibiotic therapy based on adherence to international guidelines, including the choice of antibiotic, dosing, or both, was considered for analysis. RESULTS A total of 258 patients who had a single diagnosis of an infectious disease were included. Adherence to international guidelines was noted in only 32.6% of cases; the frequency was highest for skin and soft tissue infections (50.0%), followed by urinary tract infections (40%). Among the different antibiotic classes, the highest percentage of drug incompatibility was for β-lactam prescriptions (70.8%). The percentage of incompatibility with guidelines for administered regimens on the basis of drug selection, dosing, or both was 53.4%, 10.3%, and 36.2%, respectively. CONCLUSIONS Inappropriate antibiotic use in the ED is prevalent, and physician adherence to international guidelines for empiric antibiotic prescriptions in the ED remains low. This emphasizes the importance of monitoring the use of antibiotics in the ED, as there is growing concern for antibiotic resistance and healthcare safety.
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Affiliation(s)
- Iqbal Fahs
- Department of Pharmaceutical Sciences, Lebanese International University, Mouseitbeh, Beirut, Lebanon.
| | - Zeina Shrayteh
- Department of Pharmaceutical Sciences, Lebanese International University, Mouseitbeh, Beirut, Lebanon.
| | - Rima Abdulkhalek
- Department of Pharmaceutical Sciences, Lebanese International University, Mouseitbeh, Beirut, Lebanon.
| | - Pascale Salameh
- Faculty of Pharmacy, Lebanese University, Hadath, Lebanon; Faculty of Medicine, Lebanese University, Hadath, Lebanon.
| | - Souheil Hallit
- Faculty of Pharmacy, Lebanese University, Hadath, Lebanon; Faculty of Pharmacy, Saint-Joseph University, Beirut, Lebanon; Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Kaslik, Lebanon; Research Department, Psychiatric Hospital of the Cross, Jal El Dib, Lebanon.
| | - Diana Malaeb
- Department of Pharmaceutical Sciences, Lebanese International University, Mouseitbeh, Beirut, Lebanon.
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Costantini E, Allara E, Patrucco F, Faggiano F, Hamid F, Balbo PE. Adherence to guidelines for hospitalized community-acquired pneumonia over time and its impact on health outcomes and mortality. Intern Emerg Med 2016; 11:929-40. [PMID: 27098057 DOI: 10.1007/s11739-016-1445-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 03/21/2016] [Indexed: 10/21/2022]
Abstract
Compliance with validated guidelines is crucial to guide management of patients hospitalized with community-acquired pneumonia (CAP). Data describing real-life management and treatment of CAP are limited. We aimed to evaluate the compliance with guidelines over time, and to assess its impact on all-cause mortality and clinical outcomes. We retrospectively compared two cohorts of patients admitted to the hospital, throughout 2005, just after the implementation of a local clinical pathway based on CAP international guidelines, and 7 years later over 2012. We included all patients with a diagnosis of pneumonia and/or related complications. 564 patients were included. The Pneumonia Severity Index calculation was better documented in 2012 (25.23 %) compared to 2005 (17.70 %; p = 0.032), but compliance with guideline empirical antibiotic therapy was lower in 2012 (56.70 %) than in 2005 (68.75 %; p = 0.004). Performance of guideline recommended urinary antigen tests was higher in 2012, and associated with 57.3 % lower odds of in-hospital mortality (95 % CI 15.0-78.5 %) and with 65.9 % lower odds of 30-day mortality (95 % CI 31.5-83.0 %). Compliance with empirical antibiotic therapy was associated with 2.9 days lower mean length of hospital stay (95 % CI -4.2 to -1.6 days) and with 2.0 days lower mean duration of antibiotic therapy (95 % CI -3.3 to -0.7 days). Compliance with guidelines changed over time, with some effects on mortality and with an apparent reduction in the length of hospital stay and the duration of antibiotic therapy. Specific clinical training and hospital control policies could achieve greater compliance with guidelines, and thus reduce a burden on hospital services.
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Affiliation(s)
- Elisa Costantini
- Medical Department, Division of Respiratory Medicine, Ospedale "Maggiore della Carità", Novara, Italy
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Elias Allara
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- School of Public Health, University of Torino, Turin, Italy
| | - Filippo Patrucco
- Medical Department, Division of Respiratory Medicine, Ospedale "Maggiore della Carità", Novara, Italy.
- Cardiothoracic Department, Division of Respiratory Medicine, "Città della Salute e della Scienza" Hospital and University of Torino, Turin, Italy.
- , Corso Bramante 88/90, 10126, Turin, Italy.
| | - Fabrizio Faggiano
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Fozia Hamid
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Piero Emilio Balbo
- Medical Department, Division of Respiratory Medicine, Ospedale "Maggiore della Carità", Novara, Italy
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Egger ME, Myers JA, Arnold FW, Pass LA, Ramirez JA, Brock GN. Cost effectiveness of adherence to IDSA/ATS guidelines in elderly patients hospitalized for Community-Aquired Pneumonia. BMC Med Inform Decis Mak 2016; 16:34. [PMID: 26976388 PMCID: PMC4791973 DOI: 10.1186/s12911-016-0270-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 02/29/2016] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Adherence to guidelines for the treatment of hospitalized elderly patients with community-acquired pneumonia (CAP) has been associated with improved clinical outcomes. This study evaluated the cost-effectiveness of adherence to guidelines for the treatment of CAP in an elderly hospitalized patient cohort. METHODS Data from an international, multicenter observational study for patients age 65 years or older hospitalized with CAP from 2001 to 2007 were used to estimate transition probabilities for a multi-state Markov model traversing multiple health states during hospitalization for CAP. Empiric antibiotic therapy was classified as adherent, over-treated, and under-treated according to 2007 Infectious Disease Society of America/American Thoracic Society IDSA/ATS guidelines. Utilities were estimated from an expert panel of active clinicians. Costs were estimated from a tertiary referral hospital and adjusted for inflation to 2013 US dollars. Costs, utilities, and transition probabilities were all modeled using probability distributions to handle their inherit uncertainty. Cost-effectiveness analysis was based on the first 14 days of hospitalization. Patients admitted to the intensive care unit (ICU) were analyzed separately from those admitted to the ward. Sensitivity analyses with regards to time frame (out to 30 days hospitalization), cost estimates, and willingness to pay values were performed. RESULTS The model parameters were estimated using data from 1635 patients (1438 admitted to the ward and 197 admitted to the ICU). For the ward model, adherence to antibiotic guidelines was the dominant strategy and associated with lower costs (-$1379 and -$799) and improved quality of life compared to over- and under-treatment. In the ICU model, however, adherence to guidelines was associated with greater costs (+$13,854 and + $3461 vs. over- and under-treatment, respectively) and lower quality of life. Acceptance rates across the willingness to pay ranges evaluated were 42-48 % for guideline adherence on the ward and 61-64 % for over-treatment on the ICU. Results were robust over sensitivity analyses concerning cost and utility estimates. CONCLUSIONS While adherence to antibiotic guidelines was the most cost-effective strategy for elderly patients hospitalized with CAP and admitted to the ward, in the ICU over-treatment of patients relative to the guidelines was the most cost-effective strategy.
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Affiliation(s)
- Michael E. Egger
- />The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville, School of Medicine, Louisville, KY USA
- />Present Affiliation: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - John A. Myers
- />Department of Pediatrics, University of Louisville, School of Medicine, Louisville, KY USA
| | - Forest W. Arnold
- />Department of Medicine, Division of Infectious Diseases, University of Louisville, School of Medicine, Louisville, KY USA
| | - Leigh Ann Pass
- />Pharmacy Department, University of Louisville Health Care, Louisville, KY USA
| | - Julio A. Ramirez
- />Department of Medicine, Division of Infectious Diseases, University of Louisville, School of Medicine, Louisville, KY USA
| | - Guy N. Brock
- />Department of Bioinformatics and Biostatistics, University of Louisville, School of Public Health, Louisville, KY USA
- />Present Affiliation: Department of Biomedical Informatics, The Ohio State University, College of Medicine, Columbus, OH USA
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Farida H, Rondags A, Gasem MH, Leong K, Adityana A, van den Broek PJ, Keuter M, Natsch S. Development of quality indicators to evaluate antibiotic treatment of patients with community-acquired pneumonia in Indonesia. Trop Med Int Health 2015; 20:501-9. [DOI: 10.1111/tmi.12452] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Helmia Farida
- Department of Microbiology; Faculty of Medicine, Diponegoro University and Dr. Kariadi Hospital; Semarang Indonesia
| | - Angelique Rondags
- Department of General Internal Medicine; Radboud University Medical Centre; Nijmegen The Netherlands
| | - M. Hussein Gasem
- Department of Internal Medicine; Faculty of Medicine, Diponegoro University and Dr. Kariadi Hospital; Semarang Indonesia
| | - Katharina Leong
- Department of Anesthesiology; Radboud University Medical Centre; Nijmegen The Netherlands
| | - A. Adityana
- Department of Internal Medicine; Faculty of Medicine, Diponegoro University and Dr. Kariadi Hospital; Semarang Indonesia
| | | | - Monique Keuter
- Department of General Internal Medicine; Radboud University Medical Centre; Nijmegen The Netherlands
| | - Stephanie Natsch
- Department of Pharmacy; Radboud University Medical Centre; Nijmegen The Netherlands
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11
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Mbwele B. Assessing the quality of the management skills required for lower respiratory tract infections in Kilimanjaro, Tanzania. Health (London) 2014. [DOI: 10.4236/health.2014.61004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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12
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Canut A, Delgado M. [Home hospitalization in the management of community-acquired pneumonia in Vitoria-Gasteiz]. Enferm Infecc Microbiol Clin 2013; 32:130-1. [PMID: 24246778 DOI: 10.1016/j.eimc.2013.09.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 09/16/2013] [Indexed: 11/19/2022]
Affiliation(s)
- Andrés Canut
- Servicio de Microbiología, Hospital Universitario de Álava, Álava, Vitoria, España.
| | - Miriam Delgado
- Servicio de Hospitalización a Domicilio, Hospital Universitario de Álava, Álava, Vitoria, España
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[Guidelines for the probabilistic treatment of community-acquired pneumonia: compared experience between internal medicine and emergency departments in the University Hospital of Besançon, France]. Rev Med Interne 2013; 35:231-4. [PMID: 23849903 DOI: 10.1016/j.revmed.2013.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 02/19/2013] [Accepted: 03/03/2013] [Indexed: 11/23/2022]
Abstract
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.
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Johnstone J, Mandell L. Guidelines and quality measures: do they improve outcomes of patients with community-acquired pneumonia? Infect Dis Clin North Am 2013; 27:71-86. [PMID: 23398866 DOI: 10.1016/j.idc.2012.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Community-acquired pneumonia (CAP) has a significant impact in terms of morbidity, mortality, and cost of care. Guidelines play an important role in the management of this disease, and evidence supporting the positive effects of guidelines on outcomes in patients with CAP is substantial. However, evidence supporting many of the CAP quality indicators is low, and pay-for-performance measures do not seem to influence clinically important outcomes. Future CAP quality indicators should incorporate evidence-based interventions.
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Affiliation(s)
- Jennie Johnstone
- Department of Medicine, McMaster University, West Hamilton, Ontario, Canada
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Viaris de Lesegno B, Beucher G, Lamendour N, D'Alché-Gautier MJ, Dreyfus M, Benoist G. [Continuous medical evaluation of the prevention of fetomaternal rhesus-D allo-immunization]. J Gynecol Obstet Hum Reprod 2013; 42:359-365. [PMID: 23317629 DOI: 10.1016/j.jgyn.2012.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 12/05/2012] [Accepted: 12/10/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To evaluate the prevention of fetomaternal rhesus-D allo-immunization between 2008 and 2010. This evaluation was a part of the continuous medical evaluation (CME) that is compulsory in French hospitals. It was carried out using the tools recommended by the Haute Autorité de santé. We followed the national guidelines for the prevention of fetomaternal rhesus-D allo-immunization as outlined in 2005 by the national French college of Obstetrics and Gynecology. MATERIALS AND METHODS We audited 3926 consultations in the first four months of 2008. Based on the results of the audit, actions were implemented to improve care. In 2009, we audited 4021 consultations to look for improvement, and another 3932 consultations in 2010. RESULTS In 2008, 14% of the patients had an overall optimal prevention. After actions were taken, 44% of patients in 2009 and 58% of patients in 2010 demonstrated optimal prevention (P<0,05). Especially, the prevention of fetomaternal allo-immunization has been explained for 43% of the patients in 2008 and to 90% of them in 2010. And immunoprophylaxia has been prescribed to 70% of the patients in 2008 and to 93% of them in 2010. CONCLUSION This CME has resulted in a statistically significant improvement of the prevention of allo-immunization.
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Affiliation(s)
- B Viaris de Lesegno
- Service de gynécologie-obstétrique et médecine de la reproduction, CHU de Caen-FEH, avenue de la Côte-de-Nacre, 14033 Caen cedex 9, France.
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Peix C, Vandenhende MA, Bonnet F, Lacoste D, Bernard N, Youssef J, Hessamfar M, Pometan JP, Morlat P. [Adherence between antibiotic prescriptions and guidelines in an internal medicine ward: an evaluation of professional practices]. Rev Med Interne 2013; 34:456-9. [PMID: 23318197 DOI: 10.1016/j.revmed.2012.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 11/05/2012] [Accepted: 11/26/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION This is an evaluation of professional practices (EPP) on antibiotic therapy in an internal medicine ward. MATERIAL AND METHODS A 6-month prospective review of antibiotic prescriptions and their comparisons with local and national guidelines (drug, daily dose, administration, and duration) were performed. RESULTS Antibiotic therapy on 227 infectious episodes was collected. According to local guidelines, we found 56% of totally respected (lower respiratory tract infections: 38%, urinary tract infections: 88% and skin infections: 73%), 33% of partially respected and 11% of non-appropriate prescriptions. Considering national guidelines for lower respiratory tract infections as references, the results were: totally respected prescriptions 81%, partially respected prescriptions 16%, and non-appropriate prescriptions 3%. CONCLUSION This evaluation of the prescriptions allowed setting up long-lasting actions to improve clinical practice. This approach anticipates the procedures of EPP that will be needed for hospital accreditation and highlights the importance of considering several guidelines for the interpretation of the results.
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Affiliation(s)
- C Peix
- Pharmacie, groupe hospitalier Saint-André, 1 rue Jean-Burguet, Bordeaux cedex, France
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17
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Farias M, Friedman KG, Powell AJ, de Ferranti SD, Marshall AC, Brown DW, Kulik TJ. Dynamic evolution of practice guidelines: analysis of deviations from assessment and management plans. Pediatrics 2012; 130:93-8. [PMID: 22665413 PMCID: PMC9923529 DOI: 10.1542/peds.2011-3811] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE A Standardized Clinical Assessment and Management Plan (SCAMP) standardizes the care of patients with a predefined diagnosis while actively inviting and collecting data on clinician deviations (DEVs) from its recommendations. For 3 different pediatric cardiac diagnoses managed by SCAMPs, we determined the frequency of, types of, and reasons for DEVs, which are considered to be a valuable source of information and innovation. METHODS DEVs were collected as part of SCAMP implementation. DEVs were reviewed by the SCAMP committee chairperson and by a separate protocol deviation committee; they were characterized as either justifiable (J), possibly justifiable (PJ), or not justifiable (NJ). RESULTS We analyzed 415 patients, 484 clinic encounters, and 216 DEVs. Eighty-six (39.8%) of the DEVs were J, 21 (9.7%) were PJ, and 109 (50.4%) were NJ. The percentage of NJ DEVs relative to the number of opportunities for DEV was 4.1%. J and PJ DEVs were mostly due to management of unrelated conditions (11% overall) or special circumstances (22% overall). NJ DEVs primarily involved follow-up intervals (66%) and deleted tests (24%). The reason for deviating from SCAMP recommendations was not given for 31% of DEVs, even though such information was requested. CONCLUSIONS The overall low rate of NJ DEV suggests that practitioners generally accept SCAMP recommendations, but improved capture of practitioners' reasons for deviating from those recommendations is needed. This analysis revealed multiple opportunities for improving patient care, suggesting that this process can be useful in both promulgating sound practice and evolving improved approaches to patient management.
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Affiliation(s)
| | - Kevin G. Friedman
- Cardiology, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts
| | - Andrew J. Powell
- Cardiology, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts
| | - Sarah D. de Ferranti
- Cardiology, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts
| | - Audrey C. Marshall
- Cardiology, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts
| | - David W. Brown
- Cardiology, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts
| | - Thomas J. Kulik
- Cardiology, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts,Address correspondence to Thomas J. Kulik, MD, Department of Cardiology, 300 Longwood Ave, Boston, MA 02115. E-mail:
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Delgado M, Alvarez MM, Carrascosa I, Rodríguez-Velasco M, Barrios JL, Canut A. [The routine use of the Pneumonia Severity Index in the emergency department: effect on process-of-care indicators and results in community acquired pneumonia]. Enferm Infecc Microbiol Clin 2012; 31:289-97. [PMID: 22728072 DOI: 10.1016/j.eimc.2012.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 04/24/2012] [Accepted: 04/27/2012] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate process-of-care indicators (inappropriate hospitalisation, suitability and early antibiotic treatment) and outcome indicators (length of hospital stay, hospital readmission, ICU admission, and mortality) in the management of community-acquired pneumonia (CAP) when the SEPAR/IDSA guidelines were applied. PATIENTS AND METHODS An observational retrospective study conducted on patients diagnosed with CAP during the first semester of 2007 and 2008 (186 and 161 patients, respectively) in the emergency unit of a general hospital. Differences in the process-of-care and outcome indicators between 2007 and 2008 (with and without the Pneumonia Severity Index [PSI]) were evaluated. Moreover, the indicators were compared with those obtained in 2006 (110 patients), when the current guidelines were those of SEQ/ATS. RESULTS The SEPAR/IDSA guidelines improved the following process-of-care indicators: appropriateness of treatment, unjustified hospital readmission (39.4% in 2006 vs. 8.5% in 2007 [P<.001], and 17,2% in 2008 [P=.005]), and early treatment. However, outcome indicators did not change. In 2008, a decrease in the mortality of the patients of risk classes IV-V in which the PSI had been estimated was observed in comparison with the patients in which the PSI was not estimated (2.3% vs. 28.3%; P<.001). Moreover, the mortality rate of the patients of risk classes IV-V in which the PSI had been estimated was lower than those measured using the SEQ/ATS guidelines (22.7%; P=.003). CONCLUSION SEPAR/IDSA guidelines decreased the unjustified hospital readmission. In the second year of its application an increase in the number of patients who received early treatment, and a decrease of the mortality rate of the patients of risk classes IV-V in which the PSI had been estimated, were also observed.
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Affiliation(s)
- Miriam Delgado
- Servicio de Medicina Interna, Hospital Universitario de Álava-Sede Hospital Santiago, Osakidetza-Servicio Vasco de Salud, Vitoria-Gasteiz, Spain
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19
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Asadi L, Sligl WI, Eurich DT, Colmers IN, Tjosvold L, Marrie TJ, Majumdar SR. Macrolide-Based Regimens and Mortality in Hospitalized Patients With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis. Clin Infect Dis 2012; 55:371-80. [DOI: 10.1093/cid/cis414] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
Patients admitted to the intensive care unit (ICU) often have significant underlying morbidities that require complex treatment plans. Because of these complexities, numerous guidelines have been developed to facilitate the management of the critically ill patient. Some of these guidelines include sepsis, community-acquired and ventilator-associated pneumonia, sedation, and glycemic control. Once guidelines are written, a treatment protocol must be developed and implemented within the critical care unit. Our medical center has implemented multiple treatment protocols, often with preprinted order sets with various degrees of success. In 2003, we implemented and later evaluated a sedation order form and protocol. Patients whose sedation was initiated with a standardized order form had more frequent sedation score assessment, less time between sedation vacations, reduced ICU length of ICU stay, and a trend in reduction of ventilator days. However, only 37% of eligible patients were treated using the order form and the protocol, despite the potentially beneficial effects. Some recommendations within guidelines are based on sound clinical evidence supported by randomized controlled trials, although others are based on expert opinion only. The most often-cited reason for protocol noncompliance is disagreement with the published clinical trial data. This paper examines both infectious and noninfectious treatment guidelines and the supportive evidence that they improved patient outcomes. In addition, strategies for successful implementation of a treatment guideline are discussed for clinicians to follow in order to maximize clinical outcomes.
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Affiliation(s)
- Stephen W Nissen
- Department of Pharmaceutical Services, The Nebraska Medical Center, 981090 Nebraska Medical Center, Omaha, NE, USA
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Maisel A, Neath SX, Landsberg J, Mueller C, Nowak RM, Peacock WF, Ponikowski P, Möckel M, Hogan C, Wu AHB, Richards M, Clopton P, Filippatos GS, Di Somma S, Anand I, Ng LL, Daniels LB, Christenson RH, Potocki M, McCord J, Terracciano G, Hartmann O, Bergmann A, Morgenthaler NG, Anker SD. Use of procalcitonin for the diagnosis of pneumonia in patients presenting with a chief complaint of dyspnoea: results from the BACH (Biomarkers in Acute Heart Failure) trial. Eur J Heart Fail 2012; 14:278-86. [PMID: 22302662 PMCID: PMC3284113 DOI: 10.1093/eurjhf/hfr177] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Biomarkers have proven their ability in the evaluation of cardiopulmonary diseases. We investigated the utility of concentrations of the biomarker procalcitonin (PCT) alone and with clinical variables for the diagnosis of pneumonia in patients presenting to emergency departments (EDs) with a chief complaint of shortness of breath. METHODS AND RESULTS The BACH trial was a prospective, international, study of 1641 patients presenting to EDs with dyspnoea. Blood samples were analysed for PCT and other biomarkers. Relevant clinical data were also captured. Patient outcomes were assessed at 90 days. The diagnosis of pneumonia was made using strictly validated guidelines. A model using PCT was more accurate [area under the curve (AUC) 72.3%] than any other individual clinical variable for the diagnosis of pneumonia in all patients, in those with obstructive lung disease, and in those with acute heart failure (AHF). Combining physician estimates of the probability of pneumonia with PCT values increased the accuracy to >86% for the diagnosis of pneumonia in all patients. Patients with a diagnosis of AHF and an elevated PCT concentration (>0.21 ng/mL) had a worse outcome if not treated with antibiotics (P = 0.046), while patients with low PCT values (<0.05 ng/mL) had a better outcome if they did not receive antibiotic therapy (P = 0.049). CONCLUSION Procalcitonin may aid in the diagnosis of pneumonia, particularly in cases with high diagnostic uncertainty. Importantly, PCT may aid in the decision to administer antibiotic therapy to patients presenting with AHF in which clinical uncertainty exists regarding a superimposed bacterial infection.
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Affiliation(s)
- Alan Maisel
- VA San Diego Healthcare System, San Diego, CA, USA
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Ferrer M, Menendez R, Amaro R, Torres A. The impact of guidelines on the outcomes of community-acquired and ventilator-associated pneumonia. Clin Chest Med 2012; 32:491-505. [PMID: 21867818 DOI: 10.1016/j.ccm.2011.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The correct implementation of the current guidelines for the management of community-acquired pneumonia is associated with less mortality, faster clinical stabilization, and lower costs in these patients. By contrast, implementing the current guidelines for the management of hospital-acquired pneumonia has been followed by an increase in initially adequate antibiotic treatment but has not been accompanied by a consistently improved outcome in patients.
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Affiliation(s)
- Miquel Ferrer
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Villarroel, Spain
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Aly NY, Omar AA, Badawy DA, Al-Mousa HH, Sadek AA. Audit of physicians' adherence to the antibiotic policy guidelines in Kuwait. Med Princ Pract 2012; 21:310-7. [PMID: 22236835 DOI: 10.1159/000334769] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 10/30/2011] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To audit physicians' adherence to the local antibiotic policy guidelines in government hospitals in Kuwait. MATERIALS AND METHODS The study was a retrospective review of patient records in nine hospitals between July 1 and December 31, 2008. Clinical notes and medication charts of the latest hospital admissions were checked for antibiotic prescribing. On the audit form, aspects of the prescribed antibiotic were benchmarked to the hospital antibiotic policy guidelines to evaluate adherence. RESULTS Of 2,232 reviewed records, 1,112 (49.8%) patients had 1,528 antibiotic prescriptions. Patients who received antibiotics were significantly younger than those who did not (median age: 26.3 vs. 29.8 years, p < 0.001) and their hospital stay was significantly longer (median: 4 vs. 2 days, p < 0.001). The choice of an antibiotic was appropriate and matched the policy in 806 (52.7%) prescriptions. Of such appropriate antibiotics, adherence to route of administration was observed in 768/806 (95.3%), to dose in 758 (94%), to frequency in 746 (92.6%) and to duration in 608 (75.4%). Full adherence to all aspects of antibiotic choice, dose, route, frequency and duration was achieved in 464 (30.4%) prescriptions. In 382 (25%), the antibiotics administered were not indicated. CONCLUSION There was low adherence to the local antibiotic policy guidelines. Physicians' antibiotic prescribing practices should be optimized. Adherence to, and update of, the policy is recommended.
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Affiliation(s)
- Nasser Y Aly
- Directorate of Infection Control, Ministry of Health, Al-Shamiya, Kuwait City, Kuwait.
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Rodríguez-Baño J, Paño-Pardo JR, Alvarez-Rocha L, Asensio Á, Calbo E, Cercenado E, Cisneros JM, Cobo J, Delgado O, Garnacho-Montero J, Grau S, Horcajada JP, Hornero A, Murillas-Angoiti J, Oliver A, Padilla B, Pasquau J, Pujol M, Ruiz-Garbajosa P, San Juan R, Sierra R. Programas de optimización de uso de antimicrobianos (PROA) en hospitales españoles: documento de consenso GEIH-SEIMC, SEFH y SEMPSPH. Enferm Infecc Microbiol Clin 2012; 30:22.e1-22.e23. [DOI: 10.1016/j.eimc.2011.09.018] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 09/22/2011] [Accepted: 09/27/2011] [Indexed: 01/12/2023]
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Rodríguez-Baño J, Paño-Pardo JR, Alvarez-Rocha L, Asensio Á, Calbo E, Cercenado E, Cisneros JM, Cobo J, Delgado O, Garnacho-Montero J, Grau S, Horcajada JP, Hornero A, Murillas-Angoiti J, Oliver A, Padilla B, Pasquau J, Pujol M, Ruiz-Garbajosa P, San Juan R, Sierra R. [Programs for optimizing the use of antibiotics (PROA) in Spanish hospitals: GEIH-SEIMC, SEFH and SEMPSPH consensus document]. FARMACIA HOSPITALARIA 2011; 36:33.e1-30. [PMID: 22137161 DOI: 10.1016/j.farma.2011.10.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Accepted: 10/18/2011] [Indexed: 11/28/2022] Open
Abstract
The antimicrobial agents are unique drugs for several reasons. First, their efficacy is higher than other drugs in terms of reduction of morbidity and mortality. Also, antibiotics are the only group of drugs associated with ecological effects, because their administration may contribute to the emergence and spread of microbial resistance. Finally, they are used by almost all medical specialties. Appropriate use of antimicrobials is very complex because of the important advances in the management of infectious diseases and the spread of antibiotic resistance. Thus, the implementation of programs for optimizing the use of antibiotics in hospitals (called PROA in this document) is necessary. This consensus document defines the objectives of the PROA (namely, to improve the clinical results of patients with infections, to minimise the adverse events associated to the use of antimicrobials including the emergence and spread of antibiotic resistance, and to ensure the use of the most cost-efficacious treatments), and provides recommendations for the implementation of these programs in Spanish hospitals. The key aspects of the recommendations are as follows. Multidisciplinary antibiotic teams should be formed, under the auspices of the Infection Committees. The PROA need to be considered as part of institutional programs and the strategic objectives of the hospital. The PROA should include specific objectives based on measurable indicators, and activities aimed at improving the use of antimicrobials, mainly through educational activities and interventions based more on training activities directed to prescribers than just on restrictive measures.
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Affiliation(s)
- J Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, Sevilla, España.
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Khan F, Matar I, Khudair I. Audit of the Management of Patients Admitted to Hamad General Hospital with Community-Acquired Pneumonia. Qatar Med J 2010. [DOI: 10.5339/qmj.2010.2.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
To enhance the quality of patient care, Hamad Medical Corporation (HMC) has previously adopted guidelines for the management of community-acquired pneumonia (CAP) based upon the PSI model. We audited retrospectively the management of CAP inpatients admitted to Hamad General Hospital from 1 January until 31 June, 2008 with the objective of establishing whether these HMC guidelines were being implemented appropriately. Sixty-nine patients with CAP were admitted during the study period. Guidelines for the assessment of disease severity at presentation were not followed in all patients. Appropriate antibiotic therapy was instituted in 52 (75.4%) cases. Ten patients died (14.5%). The rate of use of a severity assessment score to stratify patients with CAP based on recognized guidelines was zero and the death rate of 14.5% might reflect that noncompliance.
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Affiliation(s)
- F.Y. Khan
- *Department of Medicine, Doha, Qatar
| | - I. Matar
- *Department of Medicine, Doha, Qatar
| | - I.F. Khudair
- **Clinical Services, Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
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Matta M, Kernéis S, Day N, Lescat M, Buu Hoi A, Varon E, Gutmann L, Mainardi JL. Do clinicians consider the results of the BinaxNOW Streptococcus pneumoniae urinary antigen test when adapting antibiotic regimens for pneumonia patients? Clin Microbiol Infect 2010. [DOI: 10.1111/j.1469-0691.2010.03088.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Roger PM, De Salvador F, Schiano MH, Cua E, Rancurel S, Farhad R, Pulcini C, Bernard E. Évaluation des pratiques professionnelles, tableau de bord et bon usage de l’antibiothérapie au cours des pneumonies aiguës communautaires. Med Mal Infect 2010; 40:412-7. [DOI: 10.1016/j.medmal.2009.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2009] [Revised: 10/18/2009] [Accepted: 12/10/2009] [Indexed: 11/25/2022]
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Frei CR, Attridge RT, Mortensen EM, Restrepo MI, Yu Y, Oramasionwu CU, Ruiz JL, Burgess DS. Guideline-concordant antibiotic use and survival among patients with community-acquired pneumonia admitted to the intensive care unit. Clin Ther 2010; 32:293-9. [PMID: 20206787 DOI: 10.1016/j.clinthera.2010.02.006] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2009] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study evaluated the survival benefit of US community-acquired pneumonia (CAP) practice guidelines in the intensive care unit (ICU) setting. METHODS We conducted a retrospective cohort study of adult patients with CAP who were admitted to 5 community hospital ICUs between November 1, 1999, and April 30, 2000. The guidelines for antibiotic prescriptions were the 2007 Infectious Diseases Society of America/American Thoracic Society guidelines. Guideline-concordant antimicrobial therapy was defined as a beta-lactam plus fluoroquinolone or macrolide, antipseudomonal beta-lactam plus fluoroquinolone, or antipseudomonal beta-lactam plus aminoglycoside plus fluoroquinolone or macrolide. Patients with a documented beta-lactam allergy were considered to have received guideline-concordant therapy if they received a fluoroquinolone with or without clindamycin, or aztreonam plus fluoroquinolone with or without aminoglycoside. All other antibiotic regimens were considered to be guideline discordant. Time to clinical stability, time to oral antibiotics, length of hospital stay, and in-hospital mortality were evaluated with regression models that included the outcome as the dependent variable, guideline-concordant antibiotic therapy as the independent variable, and the Pneumonia Severity Index (PSI) score and facility as covariates. RESULTS The median age of the 129 patients included in the study was 71 years (interquartile range, 60-79 years). Sixty-two of 129 patients (48%) were male. Comorbidities included liver dysfunction (7 patients [5%]), heart failure (62 [48%]), renal dysfunction (39 [30%]), cerebrovascular disease (21 [16%]), and cancer (14 [11%]). The median (25th-75th percentile) PSI score was 119 (98-142), and overall mortality was 19% (25 patients). Patient demographics were similar between groups. Fifty-three patients (41%) received guideline-endorsed therapies. Guideline-discordant therapy was associated with an increase in inpatient mortality (25% vs 11%; odds ratio = 2.99 [95% CI, 1.08-9.54]). Receipt of guideline-concordant antibiotics was not associated with reductions in time to clinical stability, time to oral antibiotics, or length of hospital stay when patients who died were excluded from the analysis. CONCLUSION Guideline-concordant empiric antibiotic therapy was associated with improved survival among these patients with CAP who were admitted to 5 ICUs.
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Restrepo MI, Frei CR. Health economics of use fluoroquinolones to treat patients with community-acquired pneumonia. Am J Med 2010; 123:S39-46. [PMID: 20350634 DOI: 10.1016/j.amjmed.2010.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Respiratory diseases account for approximately 10% of all hospital admissions in the United States. Pneumonia constitutes 35% of these cases, with an average length of stay (LOS) of 5.1 days. It is estimated that $8.4 billion to $10 billion of all annual US hospital expenditures are attributable to community-acquired pneumonia (CAP). As such, medical decisions, including empiric antibiotic choice, potentially exert an impact on hospital LOS and associated costs. In this review, we focus on the empiric antibiotic choices and associated costs of treatment for hospitalized patients with CAP, focusing on the use of fluoroquinolone therapy as recommended by the CAP guidelines.
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Affiliation(s)
- Marcos I Restrepo
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
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Méthode d’évaluation des pratiques professionnelles (EPP) au cours de l’antibiothérapie des pneumopathies aiguës communautaires. Med Mal Infect 2010; 40:100-5. [DOI: 10.1016/j.medmal.2009.08.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Revised: 07/02/2009] [Accepted: 08/31/2009] [Indexed: 11/21/2022]
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Hausmann LRM, Ibrahim SA, Mehrotra A, Nsa W, Bratzler DW, Mor MK, Fine MJ. Racial and ethnic disparities in pneumonia treatment and mortality. Med Care 2009; 47:1009-17. [PMID: 19648832 PMCID: PMC6521966 DOI: 10.1097/mlr.0b013e3181a80fdc] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The extent to which racial/ethnic disparities in pneumonia care occur within or between hospitals is unclear. OBJECTIVE Examine within and between-hospital racial/ethnic disparities in quality indicators and mortality for patients hospitalized for pneumonia. RESEARCH DESIGN Retrospective cohort study. SUBJECTS A total of 1,183,753 non-Hispanic white, African American, and Hispanic adults hospitalized for pneumonia between January 2005 and June 2006. MEASURES Eight pneumonia care quality indicators and in-hospital mortality. RESULTS Performance rates for the 8 quality indicators ranged from 99.4% (oxygenation assessment within 24 hours) to 60.2% (influenza vaccination). Overall hospital mortality was 4.1%. African American and Hispanic patients were less likely to receive pneumococcal and influenza vaccinations, smoking cessation counseling, and first dose of antibiotic within 4 hours than white patients at the same hospital (ORs = 0.65-0.95). Patients at hospitals with the racial composition of those attended by average African Americans and Hispanics were less likely to receive all indicators except blood culture within 24 hours than patients at hospitals with the racial composition of those attended by average whites. Hospital mortality was higher for African Americans (OR = 1.05; 95% CI = 1.02, 1.09) and lower for Hispanics (OR = 0.85; 95% CI = 0.81, 0.89) than for whites within the same hospital. Mortality for patients at hospitals with the racial composition of those attended by average African Americans (OR = 1.21; 95% CI = 1.18, 1.25) or Hispanics (OR = 1.18; 95% CI = 1.14, 1.23) was higher than for patients at hospitals with the racial composition of those attended by average whites. CONCLUSIONS Racial/ethnic disparities in pneumonia treatment and mortality are larger and more consistent between hospitals than within hospitals.
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Affiliation(s)
- Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania 15206, USA.
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Frei CR, Jaso TC, Mortensen EM, Restrepo MI, Raut MK, Oramasionwu CU, Ruiz AD, Makos BR, Ruiz JL, Attridge RT, Mody SH, Fisher A, Schein JR. Medical resource utilization among community-acquired pneumonia patients initially treated with levofloxacin 750 mg daily versus ceftriaxone 1000 mg plus azithromycin 500 mg daily: a US-based study. Curr Med Res Opin 2009; 25:859-68. [PMID: 19231913 DOI: 10.1185/03007990902779749] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The 2007 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines recommend that community-acquired pneumonia (CAP) patients admitted to hospital wards initially receive respiratory fluoroquinolone monotherapy or beta-lactam plus macrolide combination therapy. There is little evidence as to which regimen is preferred, or if differences in medical resource utilization exist between therapies. Thus, the authors compared length of hospital stay (LOS) and length of intravenous antibiotic therapy (LOIV) for patients who received initial levofloxacin 750 mg daily versus ceftriaxone 1000 mg plus azithromycin 500 mg daily ('combination therapy'). RESEARCH DESIGN AND METHODS Adult hospital CAP cases from January 2005 to December 2007 were identified by principal discharge diagnosis code. Patients with a chest infiltrate and medical notes indicative of CAP were included. Direct intensive care unit admits and healthcare-associated cases were excluded. A propensity score technique was used to balance characteristics associated with initial antimicrobial therapy using multivariable regression to derive the scores. Propensity score categories, defined as propensity score quintiles, rather than propensity scores themselves, were used in the least squares regression model to assess the impact of LOS and LOIV. RESULTS A total of 495 patients from six hospitals met study criteria. Of these, 313 (63%) received levofloxacin and 182 (37%) received combination therapy. Groups were similar with respect to age, sex, most comorbidities, presenting signs and symptoms, and Pneumonia Severity Index (PSI) risk class. Patients on combination therapy were more likely to have heart failure and receive pre-admission antibiotics. Adjusted least squares mean (+/-SE) LOS and LOIV were shorter with levofloxacin versus combination therapy: LOS, 4.6 +/- 0.17 vs. 5.4 +/- 0.22 days, p < 0.01; and LOIV, 3.6 +/- 0.17 vs. 4.8 +/- 0.21 days, p < 0.01. Results for PSI risk class III or IV patients were: LOS, 5.0 +/- 0.30 vs. 5.9 +/- 0.37 days, p = 0.07; and LOIV, 3.7 +/- 0.33 vs. 5.2 +/- 0.39 days, p < 0.01. Due to the retrospective study design, limited sample size, and scope (single health-network), the authors encourage replication of this study in other data sources. CONCLUSIONS Given the LOS and LOIV reductions of 0.8 and 1.2 days, respectively, utilization of levofloxacin 750 mg daily for CAP patients admitted to the medical floor has the potential to result in substantial cost savings for US hospitals.
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Affiliation(s)
- C R Frei
- University of Texas at Austin, Austin, TX, USA.
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Niven DJ, Laupland KB. Severe community-acquired pneumonia in adults: current antimicrobial chemotherapy. Expert Rev Anti Infect Ther 2009; 7:69-81. [DOI: 10.1586/14787210.7.1.69] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Galayduyk N, Colodner R, Chazan B, Flatau E, Lavi I, Raz R. Adherence to Guidelines on Empiric Use of Antibiotics in the Emergency Room. Infection 2008; 36:408-14. [DOI: 10.1007/s15010-008-6306-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2006] [Accepted: 01/29/2008] [Indexed: 02/02/2023]
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Garau J, Baquero F, Pérez-Trallero E, Pérez JL, Martín-Sánchez A, García-Rey C, Martín-Herrero J, Dal-Ré R. Factors impacting on length of stay and mortality of community-acquired pneumonia. Clin Microbiol Infect 2008; 14:322-9. [DOI: 10.1111/j.1469-0691.2007.01915.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Treatment failure (TF) is defined as a clinical condition with inadequate response to antimicrobial therapy. Clinical response should be evaluated within the first 72 h of treatment, whereas infiltrate images may take up to 6 weeks to resolve. Early failure is considered when ventilatory support and/or septic shock appear within the first 72 h. The incidence of treatment failure in community-acquired pneumonia is 10 to 15%, and the mortality is increased nearly fivefold. Resistant and unusual microorganisms and noninfectious causes are responsible for TF. Risk factors are related to the initial severity of the disease, the presence of comorbidity, the microorganism involved, and the antimicrobial treatment implemented. Characteristics of patients and factors related to inflammatory response have been associated with delayed resolution and poor prognosis. The diagnostic approach to TF depends on the degree of clinical impact, host factors, and the possible cause. Initial reevaluation should include a confirmation of the diagnosis of pneumonia, noninvasive microbiological samples, and new radiographic studies. A conservative approach of clinical monitoring and serial radiographs may be recommended in elderly patients with comorbid conditions that justify a delayed response. Invasive studies with bronchoscopy to obtain protected brush specimen and BAL are indicated in the presence of clinical deterioration or failure to stabilize. BAL processing should include the study of cell patterns to rule out other noninfectious diseases and complete microbiological studies. The diagnostic yield of imaging procedures with noninvasive and invasive samples is up to 70%. After obtaining microbiological samples, an empirical change in antibiotic therapy is required to cover a wider microbial spectrum.
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Affiliation(s)
- Rosario Menendez
- Servicio de Neumologia, Hospital Universitario La Fe, Avda. de Campanar 21, 46009 Valencia, Spain.
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Reyes Calzada S, Martínez Tomas R, Cremades Romero MJ, Martínez Moragón E, Soler Cataluña JJ, Menéndez Villanueva R. Empiric treatment in hospitalized community-acquired pneumonia. Impact on mortality, length of stay and re-admission. Respir Med 2007; 101:1909-15. [PMID: 17628462 DOI: 10.1016/j.rmed.2007.04.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2006] [Revised: 03/27/2007] [Accepted: 04/23/2007] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate adherence to guidelines when choosing an empirical treatment and its impact upon the prognosis of community-acquired pneumonia (CAP). METHODS A prospective multicentre study was conducted in 425 CAP patients hospitalized on ward. Initial empirical treatment was classified as adhering or not to Spanish guidelines. Adherent treatment was defined as an initial antimicrobial regimen consisting of beta-lactams plus macrolides, beta-lactam monotherapy and quinolones. Non-adherent treatments included macrolide monotherapy and other regimens. Initial severity was graded according to pneumonia severity index (PSI). The end point variables were mortality, length of stay (LOS) and re-admission at 30 days. RESULTS Overall 30-day mortality was 8.2%, the mean LOS was 8+/-5 days, and the global re-admission rate was 7.6%. Adherence to guidelines was 76.5%, and in most cases the empirical treatment consisted of beta-lactam and macrolide in combination (57.4%). Logistic regression analysis showed that other regimens were associated with higher mortality OR=3 (1.2-7.3), after adjusting for PSI and admitting hospital. Beta-lactam monotherapy was an independent risk factor for re-admission. LOS was independently associated with admitting hospital and not with antibiotics. CONCLUSIONS A high adherence to CAP treatment guidelines was found, though with considerable variability in the empirical antibiotic treatment among hospitals. Non-adherent other regimens were associated with greater mortality. Beta-lactam monotherapy was associated with an increased re-admission rate.
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Affiliation(s)
- S Reyes Calzada
- Service of Pneumology, Hospital Universitario La Fe, Valencia, Spain.
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Schouten JA, Hulscher MEJL, Natsch S, Kullberg BJ, van der Meer JWM, Grol RPTM. Barriers to optimal antibiotic use for community-acquired pneumonia at hospitals: a qualitative study. Qual Saf Health Care 2007; 16:143-9. [PMID: 17403764 PMCID: PMC2653154 DOI: 10.1136/qshc.2005.017327] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Physician adherence to key recommendations of guidelines for community-acquired pneumonia (CAP) is often not optimal. A better understanding of factors influencing optimal performance is needed to plan effective change. METHODS The authors used semistructured interviews with care providers in three Dutch medium-sized hospitals to qualitatively study and understand barriers to appropriate antibiotic use in patients with CAP. They discussed recommendations about the prescription of empirical antibiotic therapy that adheres to the guidelines, timely administration of antibiotics, adjusting antibiotic dosage to accommodate decreased renal function, switching and streamlining therapy, and blood and sputum culturing. The authors then classified the barriers each recommendation faced into categories using a conceptual framework (Cabana). RESULTS Eighteen interviews were performed with residents and specialists in pulmonology and internal medicine, with medical microbiologists and a clinical pharmacist. Two additional multidisciplinary small group interviews which included nurses were performed. Each guideline recommendation elicited a different type of barrier. Regarding the choice of guideline-adherent empirical therapy, treating physicians said that they worried about patient outcome when prescribing narrow-spectrum antibiotic therapy. Regarding the timeliness of antibiotic administration, barriers such as conflicting guidelines and organisational factors (for example, delayed laboratory results, antibiotics not directly available, lack of time) were reported. Not streamlining therapy after culture results became available was thought to be due to the physicians' attitude of "never change a winning team". CONCLUSIONS Efforts to improve the use of antibiotics for patients with CAP should consider the range of barriers that care providers face. Each recommendation meets its own barriers. Interventions to improve adherence should be tailored to these factors.
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Affiliation(s)
- Jeroen A Schouten
- Centre for Quality of Care Research, Radboud University Medical Centre, Nijmegen, The Netherlands.
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Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27-72. [PMID: 17278083 PMCID: PMC7107997 DOI: 10.1086/511159] [Citation(s) in RCA: 4091] [Impact Index Per Article: 240.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Armitage K, Woodhead M. New guidelines for the management of adult community-acquired pneumonia. Curr Opin Infect Dis 2007; 20:170-6. [PMID: 17496576 DOI: 10.1097/qco.0b013e3280803d70] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Community-acquired pneumonia is a major cause of morbidity and mortality, and is the leading cause of death from an infectious disease. International societies have published and revised guidelines aiming to improve the management of adult community-acquired pneumonia, based on the best available evidence. The aim of this review is to compare the current guideline recommendations. RECENT FINDINGS Aspects of guidelines differ based on local factors including resources and antimicrobial factors, as well as the differences in interpretation of existing evidence. SUMMARY The lack of robust evidence behind aspects of guideline recommendations as well as the lack of adherence to published guidelines both need to be addressed if the management of community-acquired pneumonia is to be improved.
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Affiliation(s)
- Kathryn Armitage
- Department of Respiratory Medicine, University of Manchester, Manchester Royal Infirmary, Manchester, UK
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Schouten JA, Hulscher MEJL, Trap-Liefers J, Akkermans RP, Kullberg BJ, Grol RPTM, van der Meer JWM. Tailored interventions to improve antibiotic use for lower respiratory tract infections in hospitals: a cluster-randomized, controlled trial. Clin Infect Dis 2007; 44:931-41. [PMID: 17342644 DOI: 10.1086/512193] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2006] [Accepted: 11/25/2006] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Limited data exist on the most effective approach to increase the quality of antibiotic use for lower respiratory tract infections at hospitals. METHODS One thousand nine hundred six patients with community-acquired pneumonia or an exacerbation of chronic obstructive pulmonary disease (acute exacerbation of chronic bronchitis) were included in a cluster-randomized, controlled trial at 6 medium-to-large Dutch hospitals. A multifaceted guideline-implementation strategy that was tailored to baseline performance and considered the barriers in the target group was used. Principal outcome measures were (1) guideline-adherent antibiotic prescription, (2) adaptation of dose and dose interval of antibiotics according to renal function, (3) switches in therapy, (4) streamlining of therapy, and (5) Gram staining and culture of sputum samples. Secondary process outcomes were applicable to community-acquired pneumonia (e.g., timely administration of antibiotics) or acute exacerbation of chronic bronchitis (e.g., not prescribing macrolides). RESULTS The rate of guideline-adherent antibiotic prescription increased from 50.3% to 64.3% in the intervention hospitals (odds ratio [OR], 2.63; 95% confidence interval [CI], 1.57-4.42; P=.0008). The rate of adaptation of antibiotic dose according to renal function increased from 79.4% to 95.1% in the intervention hospitals (OR, 7.32; 95% CI, 2.09-25.7; P=.02). The switch from intravenous to oral therapy improved more in the control hospitals (from 53.3% to 71.9%) than in the intervention hospitals (from 74% to 83.6%). The change from broad-spectrum empirical therapy to pathogen-directed therapy improved by 5.7% in the intervention hospitals (P = not significant). Fewer sputum samples were obtained from both the intervention group (rate of sputum samples obtained decreased from 55.8% to 53.1%) and the control group (rate of sputum samples obtained decreased from 49.6% to 42.7%). Timely administration of antibiotics for community-acquired pneumonia increased significantly in the intervention group (from 55.2% to 62.9%; OR, 2.49; 95% CI, 1.11-5.57; P=.026). CONCLUSIONS With regard to some important aspects, tailoring interventions to change antibiotic use improved the quality of treatment for patients hospitalized with lower respiratory tract infection.
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Affiliation(s)
- Jeroen A Schouten
- Centre for Quality of Care Research, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Abstract
INTRODUCTION Evaluations of care strategies for patients with community acquired pneumonia (CAP) tend to focus more on their necessity (variation in practice...) than on efficacy (adherence, impact of markers of disease severity or medico-economic factors...). STATE OF THE ART A number of studies are reported in the literature based on a simple evaluation of practice at a given moment on time or else on the impact of guidelines. These evaluations relate either to outcome criteria (mortality, and duration of stay especially) or the economic impact of CAP (rate of hospitalization, duration of stay, costs of the treatments or hospitalizations...), or on process of care (evaluation of initial severity, delay in administration of antibiotics, appropriateness of antibiotic therapy, evaluation of oxygenation and taking of specimens prior to treatment). PERSPECTIVES AND CONCLUSIONS Taken together these studies demonstrate the need to improve and standardise care. Where studies have not found a benefit from guidelines this can often be attributed to problems with assessment or study design and there are many studies showing the benefit of guideline based management and the introduction of standardised care pathways.
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Affiliation(s)
- D Benhamou
- Service de Pneumologie, Hôpital de Bois-Guillaume, CHU, Rouen, France.
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Huang JQ, Hooper PM, Marrie TJ. Factors associated with length of stay in hospital for suspected community-acquired pneumonia. Can Respir J 2007; 13:317-24. [PMID: 16983447 PMCID: PMC2683319 DOI: 10.1155/2006/325087] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To determine factors associated with the length of stay (LOS) for patients with suspected community-acquired pneumonia (CAP) who required hospitalization for treatment. STUDY DESIGN The authors studied a population-based prospective cohort of 2,757 adults with suspected CAP who were admitted over a two-year period. Logistic regression, multiple linear regression, and classification and regression trees were used to determine the factors associated with LOS. SETTING The study was conducted in two community and tertiary care hospitals, two community and secondary care hospitals, and two community hospitals in the Capital Health Region of Edmonton, Alberta. RESULTS Symptoms such as sweats, shaking chills and wheezing were associated with an LOS of seven days or shorter, whereas weight loss, functional impairment, heart, renal or neoplastic diseases and time to first dose of antibiotic were predictive of an LOS greater than seven days. Regression tree analysis indicated that rapid achievement of physiological stability was associated with a shorter LOS. The use of an indwelling urinary catheter was found to be an important determinant of LOS. CONCLUSIONS The present study found several new associations with increased LOS in patients with CAP, including functional status, time to receipt of first dose of antibiotic therapy, use of certain antibiotics, presence of a urinary catheter and the importance of time to physiological stability. An intervention targeting avoidance of urinary catheters may be associated with a shorter LOS.
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Affiliation(s)
- Jane Q Huang
- Department of Medicine, University of Alberta, Edmonton, Alberta
- Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Alberta
| | - Peter M Hooper
- Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Alberta
| | - Thomas J Marrie
- Department of Medicine, University of Alberta, Edmonton, Alberta
- Correspondence: Dr Thomas J Marrie, Faculty of Medicine and Dentistry, 2J2.01 Walter C Mackenzie Health Sciences Centre, 8440 – 112 Street, Edmonton, Alberta T6G 2R7. Telephone 780-492-9728, fax 780-492-7303, e-mail
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Advances in lower respiratory tract infections in critically ill patients. Enferm Infecc Microbiol Clin 2007. [DOI: 10.1016/s0213-005x(07)75792-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Adverse Events in Patients With Community-Acquired Pneumonia at an Academic Tertiary Emergency Department. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2006. [DOI: 10.1097/01.idc.0000227713.81012.ae] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Recommandations en infectiologie respiratoire : quels objectifs ? Rev Mal Respir 2006. [DOI: 10.1016/s0761-8425(06)71794-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Wu JH, Howard DH, McGowan JE, Turpin RS, Henry Hu X. Adherence to infectious diseases society of America guidelines for empiric therapy for patients with community-acquired pneumonia in a commercially insured cohort. Clin Ther 2006; 28:1451-61. [PMID: 17062317 DOI: 10.1016/j.clinthera.2006.09.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is little published research addressing how the 2003 Infectious Diseases Society of America (IDSA) guidelines for empiric therapy of community-acquired pneumonia (CAP) are implemented in clinical practice. OBJECTIVE This study was designed to describe antibiotic treatment patterns among patients with CAP treated in ambulatory settings in light of the IDSA guidelines. METHODS Health insurance claims data from a large managed care organization with -30 million enrollees located in geographically diverse regions of the United States were analyzed. Patients > or =18 years of age with CAP who received a prescription for any antibiotic in an ambulatory setting during 2004 were identified via International Classification of Diseases, Ninth Revision, Clinical Modification codes for diagnosis (481-486). Recent antibiotic use was defined as receipt of any antibiotics <90 days before the date of diagnosis. Antibiotics were identified through National Drug Codes and from outpatient medical claims data with the use of J codes. Individuals were classified, per IDSA guidelines, as previously healthy without recent antibiotic use (group 1); previously healthy with recent antibiotic use (group 2); with comorbidities and without recent antibiotic use (group 3); and with comorbidities and recent antibiotic use (group 4). The guideline adherence was calculated using the number of patients receiving recommended treatment divided by the total number of patients in each group. RESULTS Of 34,342 patients identified, 76.5% had no reported comorbidities. Among group-1 patients, 52.0% received the recommended empiric therapy (macrolide or doxycycline). In group-2 patients, 42.5% received the recommended therapy (respiratory quinolone alone or advanced-generation macrolide plus amoxicillin or amoxicillin-clavulanate). A high rate of compliance with recommended empiric therapy (advanced-generation macrolides or respiratory quinolones) was observed in group-3 patients (81.5%). In group-4 patients, 43.4% received the recommended therapy (respiratory quinolone or advanced-generation macrolide plus ss-lactam). Patients whose therapy was adherent with the guidelines had fewer respiratory-infection-related hospital admissions within 30 days after initiation of antibiotic treatment (overall, relative risk = 0.81 [95% CI, 0.71-0.94]). CONCLUSION Although these data reflect a period shortly after the 2003 IDSA guidelines were published, they suggest that there is room for improvement with regard to choice of empiric antibiotic therapy among these patients with CAP treated in ambulatory settings.
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Affiliation(s)
- Jasmanda H Wu
- Department of Outcomes Research and Management, Division of US Human Health, Merck & Co., Inc., West Point, Pennsylvania 19486, USA.
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Bodí M, Rodríguez A, Solé-Violán J, Gilavert MC, Garnacho J, Blanquer J, Jimenez J, de la Torre MV, Sirvent JM, Almirall J, Doblas A, Badía JR, García F, Mendia A, Jordá R, Bobillo F, Vallés J, Broch MJ, Carrasco N, Herranz MA, Rello J. Antibiotic Prescription for Community-Acquired Pneumonia in the Intensive Care Unit: Impact of Adherence to Infectious Diseases Society of America Guidelines on Survival. Clin Infect Dis 2005; 41:1709-16. [PMID: 16288392 DOI: 10.1086/498119] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2005] [Accepted: 08/02/2005] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The purpose of our study was to analyze prognostic factors associated with mortality for patients with severe community-acquired pneumonia (CAP). METHODS We conducted a prospective multicenter study including all patients with CAP admitted to the intensive care unit during a 15-month period in 33 Spanish hospitals. Admission data and data on the evolution of the disease were recorded. Multivariate analysis was performed using the SPSS statistical package (SPSS). RESULTS A total of 529 patients with severe CAP were enrolled; the mean age (+/-SD) was 59.9+/-16.1 years, and the mean Acute Physiology and Chronic Health Evaluation (APACHE) II score (+/-SD) was 18.9+/-7.4. Overall mortality among patients in the intensive case unit was 27.9% (148 patients). The rate of adherence to Infectious Diseases Society of America (IDSA) guidelines was 57.8%. Significantly higher mortality was documented among patients with nonadherence to treatment (33.2% vs. 24.2%). Multivariate analysis identified age (odds ratio [OR], 1.7), APACHE II score (OR, 4.1), nonadherence to IDSA guidelines (OR, 1.6), and immunocompromise (OR, 1.9) as the variables present at admission to the intensive care unit that were independently associated with death in the intensive care unit. In 15 (75%) of 20 cases of Pseudomonas aeruginosa infection, the antimicrobial treatment at admission was inadequate (including 8 of 15 cases involving patients with adherence to IDSA guidelines). Chronic obstructive pulmonary disease (OR, 17.9), malignancy (OR, 11.0), previous antibiotic exposure (OR, 6.2), and radiographic findings demonstrating rapid spread of disease (OR, 3.9) were associated with P. aeruginosa pneumonia. CONCLUSIONS Better adherence to IDSA guidelines would help to improve survival among patients with severe CAP. Pseudomonas coverage should be considered for patients with chronic obstructive pulmonary disease, malignancy, or recent antibiotic exposure.
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Affiliation(s)
- M Bodí
- Intensive Care Dept., Joan XXIII University Hospital, Tarragona, Spain.
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Oosterheert JJ, Bonten MJM, Schneider MME, Hoepelman IM. Predicted effects on antibiotic use following the introduction of British or North American guidelines for community-acquired pneumonia in The Netherlands. Clin Microbiol Infect 2005; 11:992-8. [PMID: 16307553 DOI: 10.1111/j.1469-0691.2005.01286.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This study evaluated the possible changes in antibiotic use that might follow the implementation of British or North American guidelines for the treatment of community-acquired pneumonia (CAP) in The Netherlands. Patients admitted for mild, moderate and severe CAP were evaluated prospectively. Volume of antibiotic use, based upon guidelines of the British Thoracic Society (BTS), the Infectious Diseases Society of America (IDSA) or the American Thoracic Society (ATS), was estimated and compared to current practice. For 248 patients, current antibiotic use was 3087 defined daily doses. Antibiotic use would increase by 38% if based on ATS guidelines, by 23% if based on IDSA guidelines, and by 21% if based on BTS guidelines. The most significant increase in antibiotic use would occur for cases of moderate CAP, with incremental antibiotic costs of 1 750 000-3 500 000 Euros in The Netherlands.
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Affiliation(s)
- J J Oosterheert
- Division of Medicine, Department of Internal Medicine and Infectious Diseases, University Medical Center, Utrecht, The Netherlands
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