A tailored implementation strategy to reduce the duration of intravenous antibiotic treatment in community-acquired pneumonia: a controlled before-and-after study

Abstract

We previously showed that 40 % of clinically stable patients hospitalised for community-acquired pneumonia (CAP) are not switched to oral therapy in a timely fashion because of physicians' barriers. We aimed to decrease this proportion by implementing a novel protocol. In a multi-centre controlled before-and-after study, we evaluated the effect of an implementation strategy tailored to previously identified barriers to an early switch. In three Dutch hospitals, a protocol dictating a timely switch strategy was implemented using educational sessions, pocket reminders and active involvement of nursing staff. Primary outcomes were the proportion of patients switched timely and the duration of intravenous antibiotic therapy. Length of hospital stay (LOS), patient outcome, education effects 6 months after implementation and implementation costs were secondary outcomes. Statistical analysis was performed using mixed-effects models. Prior to implementation, 146 patients were included and, after implementation, 213 patients were included. The case mix was comparable. The implementation did not change the proportion of patients switched on time (66 %). The median duration of intravenous antibiotic administration decreased from 4 days [interquartile range (IQR) 2-5] to 3 days (IQR 2-4), a decrease of 21 % [95 % confidence interval (CI) 11 %; 30 %) in the multi-variable analysis. LOS and patient outcome were comparable before and after implementation. Forty-three percent (56/129) of physicians attended the educational sessions. After 6 months, 24 % (10/42) of the interviewed attendees remembered the protocol's main message. Cumulative implementation costs were <euro>5,798 (<euro>20/reduced intravenous treatment day). An implementation strategy tailored to previously identified barriers reduced the duration of intravenous antibiotic administration in hospitalised CAP patients by 1 day, at minimal cost.

South African guideline for the management of community-acquired pneumonia in adults

“…Early IVPOS of antibiotics is a central pillar of antibiotic stewardship as it reduces costs and intravenous cannula infections and encourages reduced length of hospital stay (149). Several studies have shown that it is safe to switch patients with CAP from intravenous to oral therapy when they become clinically stable (150,151). Definitions of clinical stability vary and a typical definition is given in Box 3 (151).…”

“…Several studies have shown that it is safe to switch patients with CAP from intravenous to oral therapy when they become clinically stable (150,151). Definitions of clinical stability vary and a typical definition is given in Box 3 (151).…”

The impact of a stewardship program on antibiotic administration in community-acquired pneumonia: Results from an observational before-after study

“…A controlled intervention study conducted in the Netherlands has shown decreased intravenous treatment durations after the application of a stewardship programme consisting of educational sessions and pocket cards reflecting state-of-the-art treatment for CAP. 5 Comparable results applying similar interventions have subsequently been reported in studies from Norway, the USA and Australia. [6][7][8][9][10] Altogether, the different stewardship programmes resulted in reduced antibiotic exposure for patients with CAP as well as a higher probability for correct empiric antibiotic treatment.…”

“…These findings are in line with other studies evaluating stewardship programmes in CAP. [5][6][7][8][9][10] Although the point estimates regarding the odds of receiving ≤3 days of intravenous antibiotic treatment in the follow-up period were beneficial as well, the effect sizes were too large to draw any conclusions. However, the duration was, with a median of under 3 days, already low at baseline.…”

Appropriate antibiotic management of bacterial lower respiratory tract infections

“…However, other studies and reviews have supported shorter duration of antibiotic therapy in patients with CAP and suggested that the use of biomarkers, such as PCT, may be useful in guiding both the initiation and the duration of antibiotic treatment 48 , 49 . One group of investigators documented that an implementation strategy, tailored to identify previous barriers to early switch, was associated with a reduced duration of intravenous therapy 50 . Another implemented a dedicated CAP team to manage low-risk, hospitalized CAP patients, which resulted in a reduced hospital length of stay, time to switch from intravenous antibiotics, and antibiotic duration without any adverse events 51 .…”