Increasing use of third-generation cephalosporins for pneumonia in the emergency department: may some prescriptions be avoided?

Abstract

Third-generation cephalosporins are used to treat inpatients with community-acquired pneumonia. Some of these prescriptions may be avoided, i.e. replaced by agents less likely to promote ESBL-mediated resistance. Our objectives were to assess the recent trend of third-generation cephalosporins use for pneumonia in the emergency department, and the proportion of avoidable prescriptions. This was a retrospective study of patients treated for community-acquired pneumonia in an emergency department, and subsequently hospitalized in non ICU wards. Third-generation cephalosporin prescriptions were presumed unavoidable if they met both criteria: (i) age ≥ 65 yr or comorbid condition, and (ii) allergy or intolerance to penicillin, or failure of penicillin first-line therapy, or treatment with penicillin in three previous months. Prescriptions were otherwise deemed avoidable. The proportion of patients treated with a third generation cephalosporin increased significantly from 13.9 % (6.9-24.1 %) in 2002 to 29.5 % (18.5-42.6 %) in 2012 (OR = 1.07 [1.01-1.14] , P = 0.02). This increase was independent from other factors associated with the prescription of a third-generation cephalosporin (immunocompromising condition, antibacterial therapy in three previous months, fluid resuscitation and REA-ICU class). Treatment with third-generation cephalosporin was avoidable in 118 out of 147 patients (80.3 % [72.7-86.2 %]). On day 7 after admission in the ED, treatment with third-generation cephalosporins was stopped or de-escalated in, respectively, 17 % and 32 % of patients. Antibiotic stewardship programs should be implemented to restrict the third-generation cephalosporins use for pneumonia in the emergency department.

Are third-generation cephalosporins unavoidable for empirical therapy of community-acquired pneumonia in adult patients who require ICU admission? A retrospective study

“…It is important to note that conversely to French recommendations, amoxicillin/beta-lactamase inhibitor is proposed as a possible first-line empirical beta-lactam for ICU patients with CAP in North American [11] and British [25] guidelines. Reducing the use of third-generation cephalosporins for CAP is already suggested in the emergency department [26]. …”

Are third-generation cephalosporins associated with a better prognosis than amoxicillin–clavulanate in patients hospitalized in the medical ward for community-onset pneumonia?

“…The first study population originated from a French academic centre (Centre Hospitalier Universitaire de Nantes, Nantes, France), the study period ranging from January 2002 to December 2015. Patients who were hospitalized between 2002 and 2013 have been described previously [5,20]. The second study population originated from a previously reported multicentre study in seven other French hospitals, including two academic centres [5].…”

“…In order to cover both community-acquired and healthcare-associated pneumonia and to exclude hospital-acquired pneumonia, patients transferred from another acute-care hospital to the ED were not eligible. Among eligible patients, we randomly selected 100 cases per year (except for 168 cases in 2013) using a computer-generated random number list [5,20]. Among these randomly selected cases, inclusion and exclusion criteria were subsequently applied.…”

“…Hence, from an ecological point of view, it may be preferable to treat community-onset pneumonia with amoxicillineclavulanate rather than 3GCs, although this point remains to be demonstrated. However, 3GCs have been increasingly used to treat this condition, although ceftriaxone has never been shown to be superior to other b-lactamsdespecially amoxicillineclavulanatedin communityonset pneumonia [20].…”

Incidence and proportion of avoidable prescriptions of third generation cephalosporins and fluoroquinolones in an emergency department

“…Par ailleurs, la proportion de traitement par C3G injectable a fortement augmenté entre 2002 et 2012, et il existe une forte variation de la proportion de patients traités par C3G et/ou FQ entre structures d'urgences, indépendamment de la gravité des patients [9,10]. Ces constats concordants indiquent qu'il existe une surprescription de C3G, et dans une moindre mesure de FQ dans les infections respiratoires basses traitées aux urgences.…”