Clinical implications for patients treated inappropriately for community-acquired pneumonia in the emergency department

Abstract

BackgroundCommunity-acquired pneumonia (CAP) is one of the most common infections presenting to the emergency department (ED). Increasingly, antibiotic resistant bacteria have been identified as causative pathogens in patients treated for CAP, especially in patients with healthcare exposure risk factors.MethodsWe retrospectively identified adult subjects treated for CAP in the ED requiring hospital admission (January 2003-December 2011). Inappropriate antibiotic treatment, defined as an antibiotic regimen that lacked in vitro activity against the isolated pathogen, served as the primary end point. Information regarding demographics, severity of illness, comorbidities, and antibiotic treatment was recorded. Logistic regression was used to determine factors independently associated with inappropriate treatment.ResultsThe initial cohort included 259 patients, 72 (27.8%) receiving inappropriate antibiotic treatment. There was no difference in hospital mortality between patients receiving inappropriate and appropriate treatment (8.3% vs. 7.0%; p = 0.702). Hospital length of stay (10.3 ± 12.0 days vs. 7.0 ± 8.9 days; p = 0.017) and 30-day readmission (23.6% vs. 12.3%; p = 0.024) were greater among patients receiving inappropriate treatment. Three variables were independently associated with inappropriate treatment: admission from long-term care (AOR, 9.05; 95% CI, 3.93-20.84), antibiotic exposure in the previous 30 days (AOR, 1.85; 95% CI, 1.35-2.52), and chronic obstructive pulmonary disease (AOR, 2.05; 95% CI, 1.52-2.78).ConclusionInappropriate antibiotic treatment of presumed CAP in the ED negatively impacts patient outcome and readmission rate. Knowledge of risk factors associated with inappropriate antibiotic treatment of presumed CAP could advance the management of patients with pneumonia presenting to the ED and potentially improve patient outcomes.

Impact of Antibiotic Choice on Pneumonia Readmission Rates

“…Variables collected included sex, age greater than or equal to 65, Charlson comorbidity score, Hematocrit less than 30, greater than or equal to 3 readmissions, instability at discharge, mismatch between organism sensitivity and antibiotic, current cancer, a history of anxiety or depression, and chronic lung disease. 3,12 Both the index admission diagnosis code and the readmission diagnosis code, if readmitted within 30 days, were documented. Use of any antibiotic, classified as either empiric or treatment, was recorded.…”

Predicting the Risk of Readmission in Pneumonia. A Systematic Review of Model Performance

“…None of the studies included in this review incorporated the Pneumonia Severity Index or the CURB-65 score, which are strong predictors of mortality and have also been shown to be associated with hospital readmissions (11,(20)(21)(22)(23)(24). Furthermore, the only study that included measures of in-hospital clinical trajectory and stability on discharge, robust predictors of postdischarge adverse outcomes, had very good discrimination (C statistic of 0.77); however, because of the study's low quality due to limited generalizability, incomplete ascertainment of readmissions, and lack of validation, it is unclear whether inclusion of these measures improved readmission risk prediction (11,23,(25)(26)(27).…”

Application of the Formula for Rational Antimicrobial Therapy (FRAT) to Community-Acquired Pneumonia

“…Initial empiric management of CAP in regions where comorbidity prevalence is highest is critically important as these patients are already at higher risk for CAP [71], as well as the severity and outcome of the episode [65]. Research has shown that patients with chronic disease comorbidities, such as diabetes or who smoke, are more likely to receive inappropriate therapy, have longer hospital stays, are more likely to be re-admitted in 30 days [25], and are at increased risk of death due to CAP over both short (30 days) and long term (1 year) time frames [72]. Recommendations suggest such patients should be given initial therapy of fluoroquinolones or a combination of beta-lactam+macrolide agents [5].…”

“…In a recent study by Classi, et al [24], the macrolide monotherapy failure rate was more than 1 in 5 adult patients (22.9%) and in elderly patients (≥ 65 years of age) and patients with multiple comorbidities this rate increased to almost 1 in 3. Treatment failure is associated with higher case fatality, longer hospital stays and higher total hospital charges [25]. Zhanel et al reported from phase 3 clinical trial data that significantly more patients infected with azithromycin susceptible S. pneumoniae and treated with azithromycin had clinical cure (89.4%) compared to those infected with azithromycin resistant S. pneumoniae (68.6%) (p=0.003) [26].…”