Inpatient Care of Community‐Acquired Pneumonia: The Effect of Antimicrobial Guidelines on Clinical Outcomes and Drug Costs in Canadian Teaching Hospitals

Abstract

BACKGROUND:Evidence supporting antibiotic treatment guidelines and respiratory quinolones (RQs) in community-acquired pneumonia (CAP) is limited.OBJECTIVE:To study associations among guideline adherence, specific antibiotics, clinical outcomes and antibiotic costs.METHODS:A retrospective cohort study in three tertiary care university teaching hospitals in Toronto, Ontario, studying CAP inpatients between November 1997 and June 2000. The period encompassed 12 months when an early version of empirical antibiotic guidelines was used (early cohort) and 18 months when recent guidelines (including RQs) were used (recent cohort).RESULTS:Six hundred ninety-eight cases of CAP were reviewed, and 91% were guideline adherent. In multivariable analyses, no association was observed between guideline adherence and mortality or duration of hospitalization. Guideline-adherent cases received fewer antibiotics in both cohorts and 0.9 days less of intravenous antibiotics (P=0.04) in the recent cohort. There was no significant difference in antibiotic cost according to guideline adherence, but recent cohort guideline-adherent cases had lower drug costs than early cohort guideline-adherent cases. Antibiotic selection was associated with illness severity and was mirrored by clinical outcomes, despite controlling for the pneumonia severity index (PSI). Treatment with anaerobic agents (odds ratio 2.7, P=0.001) or cephalosporin plus macrolide (odds ratio 2.7, P=0.02) was associated with higher mortality. Treatment with RQ monotherapy was associated with a 2.3 day shorter duration of intravenous therapy (P<0.0001) and a $19.19 lower total antibiotic cost (P<0.0001).CONCLUSION:Findings support empirical treatment guidelines for CAP and their recommendations regarding RQs. The association between mortality and anaerobic coverage or combination therapy may reflect prognostic information available at presentation but not captured by the PSI.

Adherence to Guidelines on Empiric Use of Antibiotics in the Emergency Room

“…However, in all fairness, it must be noted that not all studies have found such an association. For example, Marras et al [23], observed in a Canadian study that adherence to guidelines for the treatment of communityacquired pneumonia did not alter the mortality rate.…”

Burden of Community-Acquired Pneumonia in North American Adults

“…43 Numerous comparative studies have examined the mortality rate among patients hospitalized with CAP. [17][18][19][20][21][22]27,36,39,[44][45][46][47][48][49][50][51][52][53][54][55][56][57][58] Most were retrospective studies that compared different CAP management strategies. These studies demonstrated that the in-hospital mortality rate ranges from approximately 0% to 18% and the 30-day mortality rate ranges from 1% to 23%.…”

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

“…Moreover, compliance with guidelines is highly variable among clinicians [14] and may be due to individual inclination [15], [16], with differences among hospital type and characteristics [2]. Halm et al [17] identified factors associated with non-adherence to guidelines for the decision to hospitalize patients with CAP, but little information is available regarding factors that influence adherence to guidelines for the selection of treatment of CAP.…”