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116 Targets for Antibiotic and Institutional Resource Stewardship in Inpatient Community-Acquired Pneumonia

Friday, March 19, 2010
Grand Hall (Hyatt Regency Atlanta)
Timothy C. Jenkins, MD , Denver Health Medical Center and University of Colorado Denver, Denver, CO
Lilia Cervantes, MD , Denver Health Medical Center and University of Colorado Denver, Denver, CO
Sarah A. Stella, MD , Denver Health Medical Center and University of Colorado Denver, Denver, CO
Angela Keniston, MSPH , Denver Health Medical Center, Denver, CO
Allison L. Sabel, MD, PhD, MPH , Denver Health Medical Center and University of Colorado Denver, Denver, CO
Connie S. Price, MD , Denver Health Medical Center and University of Colorado Denver, Denver, CO
William J. Burman, MD , Denver Health Medical Center and University of Colorado Denver, Denver, CO
Philip S. Mehler, MD , Denver Health Medical Center and University of Colorado Denver, Denver, CO
Background: Community-acquired pneumonia (CAP) is the most common infectious disease resulting in hospitalization in the United States.

Objective: To identify aspects of the evaluation and management of CAP that may benefit from antibiotic and institutional resource stewardship efforts

Methods: We identified patients discharged with a primary diagnosis of pneumonia during a 5-month period (12/28/08 – 5/31/09) and performed medical record review for those meeting a pre-specified definition of CAP.

Results: 97 cases met criteria for CAP during the study period.  The mean age was 54 years.  Current smoking, COPD or asthma, diabetes mellitus, and alcohol abuse were common comorbidities, present in 45, 25, 24, and 19% of cases, respectively.  17 patients (18%) required admission to the intensive care unit.  Of the 80 patients admitted to floor nursing units, 28 (35%) had CURB-65 scores of 0 or 1 and were not hypoxic.  Sputum culture was ordered in 48 cases (49%); however an evaluable sample was obtained in only 17 (35%) of these cases, and a relevant pathogen was identified in only 3 (6%).  The median time from initial antibiotic administration to sputum collection was 11 hours (interquartile range 6 – 16).  Overall, the infecting pathogen was identified in only 12 cases (12%); 8 involved bacteremia.  The primary initial antibiotic regimen included ceftriaxone plus azithromycin in 86 cases (89%).  Of these, discharge therapy consisted of a 3rd antibiotic class in 67 (78%) (51 levofloxacin, 13 doxycycline).  22 patients (23%) received vancomycin for a median of 2 days during the hospitalization.  The median total duration of therapy was 10 days (interquartile range 8 – 12).  All-cause mortality was 2%, and 6 patients (6%) were re-hospitalized (for reasons other than pneumonia) during the 30-day follow-up period. 

Conclusions: Patients at low risk for mortality who may be candidates for outpatient treatment are frequently hospitalized, and the yield of sputum culture is particularly low at our institution.  Improvement in these processes may lead to more effective utilization of institutional resources.  Use of prolonged courses of therapy and 3 antibiotic classes are common and likely unnecessary in most cases.  Interventions to limit these practices may help to slow the development of antimicrobial resistance in CAP.