Compliance with Guidelines-Recommended Processes in Pneumonia: Impact of Health Status and Initial Signs

Abstract

Initial care has been associated with improved survival of community-acquired pneumonia (CAP). We aimed to investigate patient comorbidities and health status measured by the Charlson index and clinical signs at diagnosis associated with adherence to recommended processes of care in CAP. We studied 3844 patients hospitalized with CAP. The evaluated recommendations were antibiotic adherence to Spanish guidelines, first antibiotic dose <6 hours and oxygen assessment. Antibiotic adherence was 72.6%, first dose <6 h was 73.4% and oxygen assessment was 90.2%. Antibiotic adherence was negatively associated with a high Charlson score (Odds ratio [OR], 0.91), confusion (OR, 0.66) and tachycardia ≥100 bpm (OR, 0.77). Delayed first dose was significantly lower in those with tachycardia (OR, 0.75). Initial oxygen assessment was negatively associated with fever (OR, 0.61), whereas tachypnea ≥30 (OR, 1.58), tachycardia (OR, 1.39), age >65 (OR, 1.51) and COPD (OR, 1.80) were protective factors. The combination of antibiotic adherence and timing <6 hours was negatively associated with confusion (OR, 0.69) and a high Charlson score (OR, 0.92) adjusting for severity and hospital effect, whereas age was not an independent factor. Deficient health status and confusion, rather than age, are associated with lower compliance with antibiotic therapy recommendations and timing, thus identifying a subpopulation more prone to receiving lower quality care.

Determining best outcomes from community‐acquired pneumonia and how to achieve them

“…Studies that have tried to determine whether the use of, and concordance with, antibiotic guidelines improves outcomes are mostly retrospective and single centre with concordance rates ranging from 73% to just 22%. [72][73][74][75] Concordance with antibiotic guidelines is associated with a shorter median LOS but there are few conclusions on other outcomes. [72][73][74][75] There is evidence that physicians do 'over-treat' CAP and shorter courses of more narrow spectrum antibiotics can be used without adverse events.…”

“…[72][73][74][75] Concordance with antibiotic guidelines is associated with a shorter median LOS but there are few conclusions on other outcomes. [72][73][74][75] There is evidence that physicians do 'over-treat' CAP and shorter courses of more narrow spectrum antibiotics can be used without adverse events. [76][77][78] A multi-centre prospective study 79 found that a switch from i.v.…”

Mortality Benefits of Antibiotic Computerised Decision Support System: Modifying Effects of Age

“…Antibiotic CDSSs are particularly useful for antibiotic selection for empirical therapy, as optimal selection is complex when the causative pathogen is unknown 4 18 19 . Appropriate empirical treatment is crucial for the resolution of infection and the reduction of mortality 4 20 .…”

Discordance of physician clinical judgment vs. pneumonia severity index (PSI) score to admit patients with low risk community-acquired pneumonia: a prospective multicenter study

“…The PSI score was designed to identify patients with CAP at low risk for mortality (30) and guide clinicians to manage these patients as outpatients. However, multiple studies have demonstrated that a considerable proportion of patients with low pneumonia severity of illness scores (PSI ≤2) are still admitted to the hospital (22,(31)(32)(33)(34)(35)(36). Additionally, cohort studies from different parts of the world, including the United Kingdom (22), Spain (33), and the United State (37), have reported hospitalization rates of low-risk CAP patients (PSI =1-3) to be 55%, 56%, and 66%, respectively.…”

“…However, multiple studies have demonstrated that a considerable proportion of patients with low pneumonia severity of illness scores (PSI ≤2) are still admitted to the hospital (22,(31)(32)(33)(34)(35)(36). Additionally, cohort studies from different parts of the world, including the United Kingdom (22), Spain (33), and the United State (37), have reported hospitalization rates of low-risk CAP patients (PSI =1-3) to be 55%, 56%, and 66%, respectively. Implementation of evidence-based clinical guidelines has decreased hospitalization of low-risk CAP, but even in the best case scenario, the admission rate for low-risk CAP with PSI ≤2 remains high (23.9%) (14).…”