Impact of an Antimicrobial Stewardship Intervention on Shortening the Duration of Therapy for Community-Acquired Pneumonia

Department of Pharmacy, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287-5425, USA.
Clinical Infectious Diseases (Impact Factor: 8.89). 04/2012; 54(11):1581-7. DOI: 10.1093/cid/cis242
Source: PubMed


Initial management of community-acquired pneumonia (CAP) has been a Centers for Medicare 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.
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.
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 the intervention period (14% vs 34%); however, antibiotics were more frequently narrowed or 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%).
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.

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    • "These results confirm that shorter courses of therapy for CAP may be as effective as longer ones (Table 3); in addition, short-term therapy may improve patient compliance, decrease adverse effects, and minimize the emergence of bacterial resistance. In clinical practice, antimicrobial stewardship interventions may improve the management of CAP and may help reducing treatment duration [38]. "
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    ABSTRACT: Community acquired pneumonia (CAP) represents the most common cause of infection-related morbidity and mortality worldwide. Appropriate treatment of CAP is challenging and sometimes limited by the availability to obtain rapid and timely identification of the etiologic agent in order to initiate or deescalate the correct antimicrobial therapy. As a consequence, prescribers frequently select empiric antimicrobial therapy using clinical judgment, local patterns of antimicrobial resistance, and, sometimes, individual patient expectations. These issues may contribute to prolonged courses of inappropriate therapy. In this review, we discuss the evidence and recommendations from international guidelines for the management of CAP and the clinical trials that specifically addressed duration of antimicrobial therapy for CAP in adults. In randomized controlled trials comparing the clinical efficacy of a short-course antimicrobial regimen versus an extended-course regimen, no differences in terms of clinical success, bacterial eradication, adverse events, and mortality were observed. The use of biomarkers, such as procalcitonin, to guide the initiation and duration of antimicrobial therapy may reduce total antibiotic exposure and treatment duration, healthcare costs, and the risk of developing antimicrobial resistance. In clinical practice, antimicrobial stewardship interventions may improve the management of CAP and may help in reducing treatment duration. Sometimes "less is more" in CAP.
    Full-text · Article · Jan 2014 · The Scientific World Journal
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    • "Awareness of the likely causative pathogen is important to allow commencement of appropriate antimicrobial treatment . Use of clinical symptoms and signs to differentiate between bacterial and viral CAP could aid in choosing a targeted antimicrobial treatment and, therefore, decrease antibiotic consumption and reduce antimicrobial resistance (Albrich et al., 2004; Avdic et al., 2012). Choosing the right initial therapy is particularly important for patients with a mixed aetiology, who often develop severe CAP and have longer hospitalization and poorer outcomes (Jennings et al., 2008; Johansson et al., 2011; Woodhead et al., 2011). "
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    ABSTRACT: Current diagnostics for community-acquired pneumonia (CAP) include testing for a wide range of pathogens, which is costly and not always informative. We compared clinical and laboratory parameters of patients with CAP caused by different groups of pathogens to evaluate the potential for targeted diagnostics and directed treatment. In a prospective study, between April 2008 and April 2009, adult patients with CAP were tested for the presence of a broad range of possible respiratory pathogens using bacterial cultures, PCR, urinary antigen testing and serology. Of 408 patients with CAP, pathogens were detected in 263 (64.5%) patients. S. pneumoniae and influenza A virus were the most frequently identified bacterial and viral pathogens, respectively. Age had a significant effect on the prediction of aetiology (p = 0.054), with an increase in the relative contribution of viruses with advancing age. Multivariate analyses showed further that presence of cough increased the likelihood of detecting a viral pathogen (OR 5.536 95%CI: 2.130-14.390), the presence of immunodeficiency decreased the likelihood of detecting a bacterial pathogen (OR 0.595 95%CI: 0.246-1.437), and an increase in pneumonia severity index score increased the likelihood of detecting a pathogen in general. Although several variables were independently associated with the detection of a pathogen group, there were no reliable clinical predictors to distinguish between aetiologies due to substantial overlap. Therefore, testing for common respiratory pathogens is still necessary to optimize treatment.
    Full-text · Article · Dec 2013 · Journal of Medical Microbiology

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