M A J O R A R T I C L E
Impact of an Antimicrobial Stewardship
Intervention on Shortening the Duration of
Therapy for Community-Acquired Pneumonia
Edina Avdic,1Lisa A. Cushinotto,4Andrew H. Hughes,2Amanda R. Hansen,5Leigh E. Efird,1John G. Bartlett,2,3and
Sara E. Cosgrove2,3
1Departmentof Pharmacy, The Johns Hopkins Hospital, and the2Department of Medicine and3Division of Infectious Diseases, Johns Hopkins University
School of Medicine, Baltimore, Maryland;4Department of Pharmacy, Bryn Mawr Hospital, Main Line Health System, Pennsylvania; and5Department of
Pharmacy, Carilion Roanoke Memorial Hospital, Virginia
and Medicaid Services performance measure for a decade. We hypothesized that an intervention directed at
management of CAP that assesses areas not covered by the performance measures—treatment duration and
antimicrobial selection after additional microbiology data are available—would further improve CAP management.
Methods.We performed a single-center, prospective study to compare management of adult inpatients with
presumed CAP before (from 1 January 2008 through 31 March 2008) and after (from 1 February 2010 through 10
May 2010) an intervention consisting of education and prospective feedback to teams regarding antibiotic choice
and duration. The primary outcome measure was duration of antibiotic therapy in the 2 periods.
Results. There were 62 patients in the preintervention period and 65 patients in the intervention period. The
duration of antibiotic therapy decreased from a median of 10 to 7 days (P , .001), with 148 fewer days of antibiotic
therapy. The median lengths of stay were similar in the 2 groups (4 vs 5 days). A causative pathogen was identified
less frequently during theintervention period (14% vs 34%);however, antibiotics weremore frequently narrowedor
modified on the basis of susceptibility results during the intervention period (67% vs 19%). Fewer patients received
duplicate therapy within 24 hours in the intervention period (90% vs 55%).
Conclusions. The duration of therapy for CAP was excessive at our institution and was decreased with
a stewardship intervention. Confirmatory studies at other institutions are needed; efforts to assess and reduce
duration of therapy for CAP should be strongly considered.
Initial management of community-acquired pneumonia (CAP) has been a Centers for Medicare
Community-acquired pneumonia (CAP), along with
influenza, was the eighth leading cause of death in the
United States in 2007 . The Centers for Medicare and
Medicaid Services (CMS) and the Joint Commission
support quality-improvement initiatives in CAP, en-
dorsing performance measures for CAP that include
blood cultures, timely antimicrobial therapy (within
6 hours after patient presentation), appropriate antimi-
crobial selection, smoking cessation, vaccination, and
measuring mortality . Consequently, hospitals have
spent significant resources on ensuring that patients
presenting with suspected CAP receive appropriate
empirical therapy in a timely fashion. These initiatives
have been successful, as evidenced by an increase in
the national compliance rate up to 94.3% in 2009 .
On the basis of these results, the CMS recently an-
nounced that, as of 1 January 2012, the measure as-
sessing timing of initial empirical antibiotics will be
The retirement of this measure will address the sig-
in patients who may not have CAP, in order to be
compliant. Misdiagnosis of CAP has been reported in
22%–46% of cases [5–7]; thus, many patients receive
potentially unnecessary antibiotics and some have
adverse events while receiving this therapy. One study
Correspondence: Edina Avdic, PharmD, MBA, The Johns Hopkins Hospital, 600
North Wolfe St., Osler 425, Baltimore, MD 21287-5425 (firstname.lastname@example.org).
? The Author 2012. Published by Oxford University Press on behalf of the Infectious
Diseases Society of America. All rights reserved. For Permissions, please e-mail:
Received 18 October 2011; accepted 9 February 2012; electronically published
10 April 2012.
Clinical Infectious Diseases2012;54(11):1–581 7
Antibiotic Duration for CAP
CID 2012:54 (1 June)
by guest on February 2, 2016
settings are necessary to ensure generalizability of our results.
Nevertheless, our findings revealed that interventions to de-
crease duration of antibiotic therapy for CAP can be successful.
Future guidelines for management of CAP should promote the
use of shorter courses of therapy, and the CMS should consider
duration of therapy as a future CAP performance measure.
Hopkins Hospital: Vidhya Gunaseelan, for assistance with statistical
analyses; Annette Rowden, John Lindsley, and Paul Pham, for assistance
with antimicrobial stewardship interventions; and Eric Hadhazy and
Taylor Carlson, for assistance with data collection.
Financial support.This work was supported by funding from the
Centers for Disease Control and Prevention (grant R01 CI000616-01 to
S .E. C.).
Potential conflicts of interest. S. E. C. has received consulting fees
from Forest, Rib-X, and Merck and grant support from Cubist and
AdvanDx. J. G. B. has received consulting fees from Epocrates, Medscape,
and Tibotec. All other authors: No reported conflicts.
All authors have submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest. Conflicts that the editors consider relevant
to the content of the manuscript have been disclosed.
We thank the following individuals at The Johns
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