Abstract
BackgroundSix hospitals instituted a voluntary, system-wide, pathway for community acquired pneumonia (CAP). We proposed this study to determine the impact of pathway antibiotics on patient survival, hospital length of stay (LOS), and total hospital cost.MethodsData were collected for adults from six U.S. hospitals with a principal CAP discharge diagnosis code, a chest infiltrate, and medical notes indicative of CAP from 2005-2007. Pathway and non-pathway cohorts were assigned according to antibiotics received within 48 hours of admission. Pathway antibiotics included levofloxacin 750 mg monotherapy or ceftriaxone 1000 mg plus azithromycin 500 mg daily. Multivariable regression models assessed 90-day mortality, hospital LOS, total hospital cost, and total pharmacy cost.ResultsOverall, 792 patients met study criteria. Of these, 505 (64%) received pathway antibiotics and 287 (36%) received non-pathway antibiotics. Adjusted means and p-values were derived from Least Squares regression models that included Pneumonia Severity Index risk class, patient age, heart failure, chronic obstructive pulmonary disease, and admitting hospital as covariates. After adjustment, patients who received pathway antibiotics experienced lower adjusted 90-day mortality (p = 0.02), shorter mean hospital LOS (3.9 vs. 5.0 days, p < 0.01), lower mean hospital costs ($2,485 vs. $3,281, p = 0.02), and similar mean pharmacy costs ($356 vs. $442, p = 0.11).ConclusionsPathway antibiotics were associated with improved patient survival, hospital LOS, and total hospital cost for patients admitted to the hospital with CAP.
Highlights
Six hospitals instituted a voluntary, system-wide, pathway for community acquired pneumonia (CAP)
Though not explicitly stated in the guidelines, it is known from the pharmacokinetic-pharmacodynamic (PK-PD) literature that higher daily fluoroquinolone doses allow for greater antibiotic lung penetration [2]
Pathway and non-pathway groups differed with respect to Pneumonia Severity Index (PSI) risk class (p < 0.01), but were wellbalanced with respect to bacterial etiology (p = 0.2)
Summary
Six hospitals instituted a voluntary, system-wide, pathway for community acquired pneumonia (CAP). We proposed this study to determine the impact of pathway antibiotics on patient survival, hospital length of stay (LOS), and total hospital cost. The Infectious Diseases Society of America (IDSA), in conjunction with the American Thoracic Society (ATS), has published guidelines for the empiric treatment of CAP in adults [1]. Regarding ward patients, these guidelines advocate fluoroquinolone monotherapy or combination therapy with a beta-lactam plus a macrolide [1]. The 2007 guidelines were the first to specify a dose for one of the fluoroquinolones (i.e., levofloxacin 750 mg daily) [1]. This study aimed to test this theory by comparing health and economic outcomes for CAP patients treated according to a clinical pathway to those patients not treated according to the pathway
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