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DISEASE
Poor Compliance with Community-Acquired Pneumonia
Antibiotic Guidelines in a Large Australian
Private Hospital Emergency Department
Helen L. Robinson,
1
Philip C. Robinson,
2
and Michael Whitby
3
Aims: This study evaluated guideline concordance and time to administration of antibiotics in community-
acquired pneumonia (CAP) in a private Australian emergency department (ED). Two key components in the
management of CAP are timely administration and appropriate choice of antibiotic therapy. The use of anti-
biotics outside of guidelines can potentially increase rates of antibiotic resistance. Previous studies that evaluate
guideline concordance have largely been conducted in Australian public hospitals; however, private hospitals
comprise a significant portion of Australian health care. Methods: One hundred and thirty patients admitted to a
private Brisbane hospital between 01/01/2011 and 28/03/2012 with an admission diagnosis of CAP were
included. Data were collected on administration time and choice of antibiotic therapy in the ED. This was
compared with local and national CAP guidelines. Results: Concordance with antibiotic guidelines was low
(6.9%). Antibiotics with broader spectrum of action than that recommended in guidelines were frequently
prescribed. Eighty-one percent of patients received their first antibiotic within 4 hours of arriving in the ED.
Mortality was low at 0.9% in a cohort where 31% of patients were aged under 65. Conclusions: We found low
rates of concordance with CAP antibiotic guidelines and high use of broad-spectrum antibiotics. This has the
potential to lead to increased rates of antibiotic resistance. A subtle alteration to the restrictions within the
pharmaceutical benefit scheme formulary could potentially decrease the high usage of broad-spectrum anti-
biotics. However, the low mortality rate, nontoxic nature of these antibiotics, and the ease of their adminis-
tration pose a challenge to convincing clinicians to alter their practice.
Introduction
It has been estimated that there are 2 cases of
community-acquired pneumonia (CAP) per 1,000 of the
Australian adult population per year.
35
Hospital admissions
for CAP accounted for 4% of all hospital admissions in pa-
tients >65 years of age in Victorian hospitals between 2000
and 2002.
33
When compared with similar patients admitted
for other diagnoses, CAP is associated with longer hospital
length of stay, increased likelihood of requiring intensive care
admission, and increased mortality.
33
Key components in the
management of pneumonia are timely administration and
appropriate choice of empiric antibiotics.
Early administration of antibiotics in CAP is associated
with reduced mortality and decreased hospital length of stay
in patients over the age of 65,
5,16,26
although the same as-
sociation has not been demonstrated in patients under 65.
15
The Infectious Diseases Society of America (IDSA) pub-
lished CAP guidelines in 2003 recommending the admin-
istration of antibiotics within 4 hours of arriving in the
emergency department (ED).
20
This 4-hour target soon be-
came linked to financial reimbursement in U.S. hospitals.
20
However, it was later found that the effect of the 4-hour
target was to increase the misdiagnosis of CAP and increase
inappropriate antibiotic administration.
20
The IDSA guide-
lines were later changed to recommend no specific time
target for antibiotic administration but recommend that the
first dose be given in the ED.
20,23
Currently there is no
guidance in Australia or New Zealand with regards to the
timing of antibiotics in CAP from either the Australian
College of Emergency Medicine, The Thoracic Society of
Australia and New Zealand, or the Australasian Society for
Infectious Diseases. While a balance between the timing of
antibiotic administration and ensuring the correct diagnosis
1
Department of Medicine, Ipswich Hospital, Ipswich, Australia.
2
Department of Medicine, Princess Alexandra Hospital, University of Queensland Diamantina Institute, Brisbane, Australia.
3
Department of Medicine, Greenslopes Clinical School, University of Queensland, Brisbane, Australia.
MICROBIAL DRUG RESISTANCE
Volume 00, Number 00, 2014
ªMary Ann Liebert, Inc.
DOI: 10.1089/mdr.2014.0064
1
must be maintained, evidence has demonstrated that delays
in antibiotic administration are associated with increased
mortality.
16,26
Appropriate choice of empiric antibiotics is a key com-
ponent in the management of CAP. Guidelines provide
similar recommendations on the choice of antibiotics in
CAP in Queensland and Australia.
1,8
The vast majority of
CAP in Australia can be treated successfully with narrow-
spectrum beta-lactam treatment combined with doxycycline
or a macrolide.
9
The use of broader spectrum antibiotics has
the potential to increase rates of antibiotic resistance that is
proving a major problem in Australia and international-
ly.
12,21
Antibiotic-resistant bacteria are associated with in-
creased morbidity, mortality, and increased health care
costs.
37
Thus, the Australian Commission for Safety and
Quality in Health Care has listed antibiotic stewardship as
one of its key priority areas and mandatory for hospital
accreditation.
3
Most studies of antibiotic use in patients with CAP in
Australia have been in large public teaching hospitals.
9,24,25
These hospitals generally promote good access to local and
national guidelines, and often have restrictions on the use of
‘‘last-line antibiotics.’’ While each private hospital is dif-
ferent, some do not have intense promotion of therapeutic
guidelines nor restrictions on antibiotic use other than those
of the Pharmaceutical Benefits Scheme (PBS; the central
government pharmaceutical agency). Given that the private
hospital sector makes up a significant proportion of Aus-
tralian health care, it is important to be aware of antibiotic
use in these hospitals.
30
The aim of this study was to evaluate the management of
pneumonia in a large private Brisbane hospital ED. Timing
of antibiotic administration and choice of antibiotics were
key outcome measures of this study.
Patients and Methods
A 500-bed private Brisbane hospital with an ED was the
setting for the study. All patients 18 years of age and older
whose hospital admission was coded as pneumonia as per
ICD-10 codes J10-18 were eligible for the study. Case notes
were examined and patients were included if the emergency
physician documented a diagnosis of pneumonia or lower
respiratory tract infection. At the time of this study, this
hospital did not have restrictions on the use of antibacterial
agents, nor did it have on-line access to antimicrobial
guidelines via the hospital intranet, but staff did have
general internet access. No staff were employed for the
purpose of promoting antimicrobial stewardship and there
was only one full-time infectious disease physician (private
practitioner).
Patients were excluded from the study if they were neu-
tropenic, had suspected nosocomial infection, had suspected
aspiration pneumonia, or had commenced antibiotic therapy
prior to ED presentation. Patients were also excluded if they
had a concurrent infection that may have influenced anti-
biotic prescribing and hospital length of stay. Patients who
had treatment initiated at another hospital and were trans-
ferred to the study hospital or admitted directly onto the
ward from a specialist outpatient clinic were also excluded.
For each patient the following data were collected: age;
gender; date of birth; time of ED triage; triage allocation as
per the Australasian Triage Score
4
(range 1–5, 1—most
acute, 5—least acute); the highest pneumonia severity
confusion, oxygen, respiratory rate, and blood pressure
(CORB) score while in the ED up to 24 hours after arrival
(as per CORB score definition, confusion +/-, oxygen
saturation <90%, respiratory rate ‡30, and systolic blood
pressure [BP] <90 mmHg or diastolic BP £60 mmHg;
range 0–4, 0—least severe, 4—most severe)
7
; time of first
antibiotic administration; time of second antibiotic admin-
istration; time of administration of antibiotic with action
against Streptococcus pneumoniae (Streptococcus cover);
time of administration of antibiotic with action against
atypical respiratory organisms, such as Legionella,Myco-
plasma, and Chlamydophila (atypical cover); choice of first
and second antibiotic; chest radiograph or chest computed
tomography (CT) report; mortality; and length of stay.
Patients whose chest radiographs or chest CT scans were
subsequently reported as not having consolidation were in-
cluded in the analysis of time to antibiotics and choice of
antibiotics, as the emergency physician had treated them as
though they had pneumonia. These patients were not in-
cluded in analyses evaluating length of stay and mortality.
Antibiotic prescribing was audited against the Queens-
land Health (State Public Health Provider) guidelines
8
and
the National Antimicrobial Guidelines.
1
Both guidelines
recommend specific antibiotics depending on the severity of
the pneumonia as measured by the CORB score
7
and differ
only in regard to the recommended macrolide in CORB
score 0–1. Prescribing was deemed to be concordant when
the guidelines of either resource were met; antibiotics re-
commended by the guidelines are shown in Table 1. The
choice of antibiotic needed to be correct, as did the dose,
frequency, and route of administration. If a patient had an
allergy to the recommended first-line antibiotic and was
prescribed the recommended second-line antibiotic, then
prescribing was deemed to be concordant.
Data were analyzed with the statistical program R. Re-
lationships between continuous variables were measured
with linear regression and relationships with binary out-
comes were examined using logistic regression. p-Values
of <0.05 were deemed significant. Ethics approval was granted
from the Hospital’s Research and Ethics Committee.
Results
One hundred and thirty-two patients met the inclusion
criteria. Two patients were subsequently excluded due to
lack of documentation, leaving 130 cases in the study. One
patient was initially thought to have a pulmonary embolus;
however, a CT pulmonary angiogram showed consolidation.
This patient was excluded from the evaluation of the time to
antibiotic administration but was included in the evaluation
of antibiotic prescribing. Sixteen patients were excluded
from analyses involving length of stay and mortality. Eleven
of these patients had no consolidation seen on either their
chest radiograph or CT scan and radiology reports were not
available for 5 patients.
Patient demographics are shown in Table 2. A summary
of the timing of antibiotic administration is shown in Table 3.
All patients had their antibiotics started in the ED. One
patient died as an inpatient, giving a mortality rate of 0.9%
(1/114).
2 ROBINSON ET AL.
CORB severity scores and triage allocation are shown in
Table 4.
Appropriateness of antibiotic prescribing
Nine outof 130 patients(6.9%) were correctly prescribed the
recommended antibiotics when audited against the guidelines
(see Table 5). One hundred and four (104/130, 80%) patients
were prescribed antibiotics with broader spectrum of action
than recommended. Eight patients were given antibiotics with
a smaller spectrum of action than recommended, five patients
were given the correct antibiotics but via the wrong route of
administration, three patients were given no atypical cover, and
one patient was given inappropriate Streptococcus cover, being
gentamicin.
One of 104 patients (1%) with a CORB score of 0 or 1
was prescribed the recommended antibiotics. Ninety-eight
percent (102/104) of patients were prescribed an antibi-
otic with broader spectrum of action than benzylpenicillin
and one patient was prescribed moxifloxacin IV when it
should have been oral. Eighty of the patients who were
prescribed an antibiotic with a broader spectrum of ac-
tion than benzylpenicillin (80/102, 78%) were prescribed
ceftriaxone. Other antibiotics included timentin, ceftazidine,
augmentin, amoxycillin, ampicillin, and gentamicin. Twenty-
threepatientswithaCORBscoreof0or1werenotpre-
scribed atypical cover (23/104, 22%). Of the 81 patients who
were prescribed atypical cover, 27 (33%) were prescribed
azithromycin.
Eight out of 26 patients with a CORB score of 2 or more
(31%) were prescribed the recommended antibiotics. Most pa-
tients (85%) were prescribed appropriate Streptococcus cover.
Of the 18 patients who were not prescribed the recommended
antibiotics, 7 were prescribed either oral roxithromycin or
clarithromycin, 4 were prescribed oral azithromycin, 3 were
prescribed no atypical cover, and 4 were prescribed incorrect
Streptococcus cover. Incorrect Streptococcus cover included
benzylpenicillin, timentin, and gentamicin.
Table 1. Recommended Antibiotics as per Queensland Health/National Antimicrobial Guidelines
CORB 0–1 CORB 2–4
No penicillin
allergy
Benzylpenicillin
1.2 g 6 hourly IV
AND Doxycycline 100 mg
12 hourly po
OR
Benzylpenicillin 1.2 g
4 hourly IV PLUS
Gentamicin
4–6 mg/kg daily IV
OR
AND Azithromycin
500 mg daily IV
Roxithromycin 150 mg
12 hourly po or
300 mg daily po
OR
Ceftriaxone 1 g
daily IV
OR
Clarithromycin 500 mg
12 hourly po
Cefotaxime 1 g
daily IV
Penicillin
hypersensitivity
a
Ceftriaxone
1 g daily IV
OR
AND Doxycycline 100 mg
12 hourly po
OR
Ceftriaxone 1 g
daily IV
OR
AND Azithromycin
500 mg daily IV
Cefotaxime
1 g 8 hourly IV
Roxithromycin 150 mg
12 hourly po or
300 mg daily po
OR
Cefotaxime 1 g
8 hourly IV
Clarithromycin 500 mg
12 hourly po
Based on references.
1,8
a
For immediate penicillin hypersensitivity: Moxifloxacin 400 mg daily po for CORB 0–1 and use Moxifloxacin. Moxifloxacin 400 mg
daily IV plus Azithromycin 500 mg daily IV for CORB 2–4.
CORB, confusion, oxygen, respiratory rate, and blood pressure; po, oral.
Table 2. Demographics and Time to Antibiotic Results
Metric Result
Number 130
Percentage female gender 52% (62 male: 68 female)
Median age 76 years (IQR =64–86, total range =29–93)
Number receiving one antibiotic 25
Number receiving two antibiotics 105
Median time to first antibiotic 140 minutes (IQR =81–210 minutes)
Median time to second antibiotic 177 minutes (IQR =111–313 minutes)
Median time to Streptococcus cover 145 minutes (IQR =92–210 minutes)
Median time to atypical cover 170 minutes (IQR =99–284 minutes)
IQR, interquartile range.
ANTIBIOTIC COMPLIANCE IN PNEUMONIA 3
Correlations between variables
An increase in CORB score of 1 was associated with an
increased length of stay of 1.4 days (Table 6). Increased
length of stay also correlated with increased time to atypical
cover. However, there was no correlation between length of
stay and whether or not atypical cover was administered,
suggesting that the correlation between length of stay and
time to atypical cover was not causal.
An increase in CORB score of 1 was associated with an
increase in time to antibiotic two and time to atypical cover
of 69 and 73 minutes, respectively. An increase in age of 10
years was associated with an increase in time to antibiotic
one and time to atypical cover of 14 and 33 minutes, re-
spectively. There was a trend toward older age also being
associated with later administration of antibiotic two.
Triage score was not correlated with CORB score or the
time to antibiotic administration.
Discussion
Antibiotic stewardship is a global problem. Similar
studies overseas have shown low concordance rates with
local antibiotic guidelines.
22,34,36
Concordance with CAP
antibiotic guidelines in this study was particularly low at
only 6.9% of patients. The reason for the low concordance
mostly relates to use of third-generation cephalosporins for
nonsevere CAP rather than the recommended penicillin.
When cephalosporins were the first-line recommendation, as
in severe pneumonia, concordance rates were much higher.
This suggests that clinicians have a single antibiotic agent
that they use for all severity classes of pneumonia. McIntosh
et al. also found a high use of broad-spectrum cephalospo-
rins in their study of CAP treatment in 37 EDs in Aus-
tralia.
25
They highlighted that there is tension between the
restrained use of ceftriaxone and the benefits of using an
effective agent.
Cephalosporins were recommended first-line inpatient
therapy for nonsevere CAP in Australia from 1992 until
1998.
2
Guidelines later changed to recommend penicillin-
based treatment and cephalosporins only in the case of al-
lergy.
38
Cephalosporins have been criticized on the basis
that they lead to resistance and to the selection of multi-
resistant organisms.
10
Prior third-generation cephalosporin
use has been shown to be a risk factor for infection with
methicillin-resistant Staphyloccocus aureus, cephalosporin-
resistant Enterobacter species, and nosocomial bacteremia
with enterococci.
14,18,19,27–29
Charles et al. showed that
narrow-spectrum beta-lactam treatment was sufficient for
the majority of patients with CAP in Australia and that the
use of such treatment could potentially reduce the rates of
antibiotic resistance.
9
Antimicrobial stewardship is like many interventions in
infection control, contingent on clinician behavior. Doctors
focus on the outcome of their individual patient at the time.
This is not surprising and probably reflects the ethos and
training of physicians. It is of significance that the mortality
rate in this study was so low at 0.9% when similar studies of
patients 65 years and older with CAP found inpatient mor-
tality rates of 7% and 16.3%. Forty patients in our study
were under the age of 65 and a large proportion of patients
had a CORB score of 0 (36%) giving them a lower expected
mortality rate.
7
It is possible that this hospital admitted
patients who would have been declined admission to the
public hospitals where most studies have previously been
conducted, on the basis that they were not unwell enough to
warrant admission. This may be a finding of private hospi-
tals in general. The excellent outcomes in this study pose a
barrier to convincing clinicians to change their antimicrobial
prescribing.
The use of cephalosporins for the treatment of CAP is a
universal phenomenon.
25
This is not altogether surprising
when third-generation cephalosporins have an appropriate
spectrum of activity for community-acquired pathogens; they
are nontoxic and easy to administer.
10
One could be forgiven
Table 3. Proportion of Patients Receiving Antibiotics Within 4, 6, and 8Hours
Antibiotic
one (%)
Antibiotic
two (%)
Streptococcus
cover (%)
Atypical
cover (%)
Percentage treated within 4 hours 81 63 81 64
Percentage treated within 6 hours 95 80 94 82
Percentage treated within 8 hours 98 87 97 88
Table 4. Pneumonia Severity Score
and Triage Category
CORB score Number
046
158
219
36
41
Triage allocation Number
10
211
368
449
52
Table 5. Concordance with Antibiotic
Prescribing Guidelines
Number
Concordance
with
guidelines (%)
Discordance
with
guidelines (%)
All patients
(CORB 0–4)
130 6.9 93.1
CORB score 0–1 104 1.0 99.0
CORB score 2–4 26 31.0 69.0
4 ROBINSON ET AL.
for asking whether the use of cephalosporins as primary
treatment for CAP in Australian EDs poses such a risk that
clinicians should be dissuaded from using them. This is a
difficult question to answer and one that probably deserves
debate from the medical community.
Concordance with antibiotic guidelines in this Australian
private hospital was particularly low when compared with
studies that evaluate antibiotic prescribing in CAP in predomi-
nantly public Australian hospitals. Two similar studies under-
taken in primarily public Australian hospitals found concordance
rates of 18% and 20%.
24,25
In 2007/8, private hospitals in Aus-
tralia treated 40% of all hospital inpatients
30
and given the likely
further increase in the number of patients treated in the private
health system; antimicrobial stewardship within the private
sector is of upmost importance. The primary restriction to anti-
biotic prescribing in private hospitals is the PBS. The PBS limits
the use of third-generation cephalosporins to the treatment of
meningitis or where septicemia with a sensitive organism is
suspected. About 4–25% of CAP caused by classical pathogens
will present with bacteremia so the use of cephalosporins in this
circumstance is not a breach of PBS restrictions.
11,31
Asubtle
change to the PBS clause to exclude the setting of pneumonia
would resolve the issue. Education interventions, mostly con-
ducted in public hospitals, have also been found to increase rates
of adherence to CAP guidelines in Australia.
25
If such education
interventions were utilized by private hospitals, then this could
potentially further improve guideline adherence.
Studies of concordance with antibiotic guidelines interna-
tionally have shown a high inappropriate use of fluoro-
quinolones.
17,34,36
In our study fluoroquinolones were
administered only in the case of immediate penicillin hyper-
sensitivity as per the guidelines. This suggests that clinicians
are aware of the need to reduce their use of fluoroquinolones.
Increasing age was associated with increased time to an-
tibiotic delivery. Older patients do not always present with
classical respiratory symptoms.
6,13
This has the potential to
lead to a delay in diagnosis with a subsequent delay in the
time to antibiotic administration. It is difficult to explain why
the triage score did not correlate with either the CORB score
or the time to antibiotic administration. The Australasian
Triage Scale stipulates how quickly patients with specific
triage scores should receive medical assessment and treat-
ment. The triage score that a patient receives is based on the
severity of their observations and presenting complaint when
first assessed by the triage nurse in the ED waiting room.
One would have expected patients with higher CORB scores
to have been given lower triage scores and to have conse-
quently received their antibiotics earlier. The lack of asso-
ciation between the CORB score and the triage score may be
explained by the fact that the CORB score is by definition the
worst score while the patient is in the ED, whereas the triage
score is calculated at the time of arrival to the ED.
Eighty-one percent of patients received their first antibiotic
within 4 hours of arriving in the ED. This result is better than
previous studies from the United States where 54–66% of
patients received their first antibiotic within 4 hours.
16,20,32
This hospital therefore compares favorably with hospitals
internationally.
The study is limited in that it only looks at ED-initiated
antibiotics and not ward-based prescribing. It was also not
possible to determine whether the ED physician or the pa-
tient’s attending doctor decided on the choice of antibiotic.
The study also assumes that all patients admitted with
pneumonia were coded appropriately. Patients initially di-
agnosed with pneumonia in the ED, who subsequently had
their diagnosis changed, will have been missed by this
study. Further, as the study was retrospective, it was not
possible to determine whether antibiotics that were not
concordant with guidelines had been chosen for a specific
reason unless this was documented. However, it is highly
Table 6. Correlates Between Variables in the Study Assessed Using Linear Regression
Item one (x) Item two (y) R
2
p-Value
Estimated change
in x with change in y
LOS TTAB 1 NA 0.52 NA
LOS (hours) TTAB 2 (hours) NA 0.64 NA
LOS TT antistrep NA 0.10 NA
LOS (hours) TT atypical (hours) 0.034 0.04 4.1 hours
TTAB 1 (minutes) Age (years) 0.039 0.02 1.4 minutes
TTAB 1 CORB 0.001 0.75 NA
TTAB 1 Triage 0.006 0.37 NA
TTAB 2 (minutes) Age (years) 0.036 0.05 3.2 minutes
TTAB 2 (minutes) CORB (points) 0.050 0.02 69 minutes
TTAB 2 Triage 0.005 0.49 NA
TT antistrep Age 0.007 0.35 NA
TT antistrep CORB 0.001 0.73 NA
TT antistrep Triage 0.007 0.35 NA
TT atypical (minutes) Age (years) 0.038 0.047 3.3 minutes
TT atypical (minutes) Triage 0.003 0.55 NA
TT atypical (minutes) CORB (points) 0.056 0.02 73 minutes
LOS (days) CORB (points) 0.056 0.01 1.4 days
LOS Triage NA 0.94 NA
CORB score Triage NA 0.08 NA
CORB, CORB score (see ‘‘Materials and Methods’’); LOS, length of stay; NA, not applicable; TTAB 1, time to antibiotic one; TTAB 2,
time to antibiotic two; TT antistrep, time to Streptococcus cover; TT atypical, time to atypical cover.
ANTIBIOTIC COMPLIANCE IN PNEUMONIA 5
unlikely that these limitations were sufficient to explain the
low concordance rate that we found.
Further studies of other private Australian hospitals are
required to determine whether the low concordance rate that
we found is common in the private sector. If it is common,
then there needs to be debate about increasing PBS re-
strictions on antibiotic prescribing.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Helen Robinson, MBChB, FRACP
Department of Medicine
Ipswich Hospital
Ipswich
Queensland 4305
Australia
E-mail: robinsonhelenlouise@gmail.com
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