A Pathway for Community-Acquired Pneumonia With Rapid Conversion to Oral Therapy Improves Health Care Value

Abstract

BACKGROUND Evidence supports streamlined approaches for inpatients with community-acquired pneumonia (CAP) including early transition to oral antibiotics and shorter therapy. Uptake of these approaches is variable and best approaches to local implementation of infection-specific guidelines are unknown. Our objective was to evaluate the impact of a clinical decision support (CDS) tool linked with a clinical pathway on CAP care. METHODS This is a retrospective, observational pre-post intervention study of inpatients with pneumonia admitted to a single academic medical center. Interventions were introduced in three sequential six-month phases; Phase 1: Education alone; Phase 2: education and a CDS driven CAP pathway coupled with active antimicrobial stewardship and provider feedback, and Phase 3: education and CDS driven CAP pathway without active stewardship. The twelve months preceding the intervention were used as a baseline. Primary outcomes were length of intravenous antibiotic therapy and total length of antibiotic therapy. Clinical, process and cost outcomes were also measured. RESULTS The study included 1021 visits. Phase 2 was associated with significantly lower length of intravenous and total antibiotic therapy, higher procalcitonin lab utilization and a 20% cost reduction compared to baseline. Phase 3 was associated with significantly lower length of intravenous antibiotic therapy and higher procalcitonin lab utilization compared to baseline. CONCLUSIONS A CDS-driven CAP pathway supplemented by active antimicrobial stewardship review led to the most robust improvements in antibiotic use and decreased costs with similar clinical outcomes.

A Statewide Collaborative Quality Initiative to Improve Antibiotic Duration and Outcomes in Patients Hospitalized With Uncomplicated Community-Acquired Pneumonia

“…Third, there was no control group. Although other studies suggest that antibiotic duration has improved less than seen in the current study [ 10–12 , 29 , 33–35 ], we cannot exclude secular trends as the reason for improvement. Fourth, the decline in adverse events was driven by patient-reported adverse events, which were not available for all patients.…”

Improving management and antimicrobial stewardship for bacterial and fungal infections in hospitalized patients with COVID-19

“… 23 AMS programmes for CAP have been shown to reduce intravenous therapy, the length of antibiotic therapy and hospital stay, and expenditure on antibiotics and to be long-lasting. 24 , 25 AMS interventions for CAP include differentiating viral from bacterial aetiologies, performing an adequate diagnostic work-up, an early switch to oral antibiotics and short therapy. A recent meta-analysis showed that 24.5% of CAP have a viral aetiology and molecular testing for virus and atypical pathogens has been demonstrated to reduce the use of intravenous antibiotics.…”