Guidelines For Treatment Of Community-acquired Pneumonia Research Articles

Antibiotic Guideline Adherence at the Emergency Department: A Descriptive Study from a Country with a Restrictive Antibiotic Policy.

Denmark has a low level of antimicrobial resistance (AMR). Patients hospitalized with suspected infection often present with unspecific symptoms. This challenges the physician between using narrow-spectrum antibiotics in accordance with guidelines or broad-spectrum antibiotics to compensate for diagnostic uncertainty. The aim of this study was to investigate adherence to a restrictive antibiotic guideline for the most common infection in emergency departments (EDs), namely community-acquired pneumonia (CAP). This multicenter descriptive cross-sectional study included adults admitted to Danish EDs with a suspected infection. Data were collected prospectively from medical records. We included 954 patients in the analysis. The most prescribed antibiotics were penicillin with beta-lactamase inhibitor at 4 h (307 (32.2%)), 48 h (289 (30.3%)), and day 5 after admission (218 (22.9%)). The empirical antibiotic treatment guidelines for CAP were followed for 126 (31.3%) of the CAP patients. At 4 h, antibiotics were administered intravenously to 244 (60.7%) of the CAP patients. At day 5, 218 (54.4%) received oral antibiotics. Adherence to CAP guidelines was poor. In a country with a restrictive antibiotic policy, infections are commonly treated with broad-spectrum antibiotics against recommendations.

901. Evaluation of Azithromycin Usage Following a Pharmacist Discontinuation Protocol

Abstract Background Azithromycin usage along with a beta-lactam is common in hospitalized patients with community-acquired pneumonia (CAP). The total recommended dosage is 1500mg as either 500mg on day one followed by 250mg daily for 4 days or 500mg daily for 3 days. It was observed that total doses of >1500mg were frequently administered at our institution. Institutional empiric treatment guidelines for CAP were updated and educational sessions were given for medicine providers in November 2019 to emphasize a total dose of 1500mg. This was further followed in April 2020 by the creation of a pharmacist collaborative practice agreement (CPA) to allow any unit-based clinical pharmacist to discontinue azithromycin for CAP after administration of a sum total of 1500mg. Methods A retrospective quasi experimental study was performed to evaluate the impact of implementing a pharmacist CPA for discontinuation of azithromycin for CAP. The primary objective was to compare the proportion of patients receiving greater than 1500mg of azithromycin during the pre-implementation period of April 2018-March 2020 to the post-implementation period of April 2020-March 2022. Pre- and post-implementation period rates were compared using a Chi-square test. Secondarily, utilization of CPA as the discontinuation method was evaluated. Results A total of 8,373 patients were included (5123 pre and 3250 post) in the analysis. The proportion of patients receiving >1500mg of azithromycin decreased from 29.32% pre-implementation to 20.22% post-implementation (P< 0.001). There was a decrease seen immediately after implementation that has been maintained over time, as shown in figure 1. The CPA was utilized for discontinuation in a minority of patients during the post-implementation period and the majority discontinued by pharmacists were per verbal order. Percentage of Patients Receiving >1500mg Azithromycin Conclusion Implementation of a pharmacist driven CPA for discontinuation of azithromycin for CAP reduced excessive azithromycin usage with minimal time burden for the AMS team. To further meet the goal of decreasing excessive azithromycin usage additional interventions are needed, and low utilization of the CPA should be further evaluated. Disclosures Kelly M. Percival, PharmD, Gilead Sciences Inc: Advisor/Consultant Patrick M. Kinn, PharmD, MPH, Gilead Sciences: Advisor/Consultant Dilek Ince, MD, Evergreen: Member of data monitoring board|Gilead Sciences: Grant/Research Support|Leidos: Grant/Research Support|Moderna: Grant/Research Support.

519. Longer Length of Antibiotic Therapy for Community-Acquired Pneumonia and Risk of Clostridium difficile Infection

BackgroundWe previously observed a median 9.5 days length of antibiotic therapy (LOT) among patients with community-acquired pneumonia (CAP) requiring hospitalization (Clin Infect Dis. 2018;66:1333–41). Treatment guidelines for CAP, however, suggest LOT >7 days is rarely necessary. In this study, we evaluated the risk of Clostridium difficile infection (CDI) as a potential harm of longer LOT.MethodsThis retrospective cohort study included Medicare beneficiaries with parts A, B, and D coverage hospitalized for uncomplicated CAP in 2012–2013 for 2–10 days, home discharge, and no hospitalizations 30 days before or 3 days after index hospitalization. The main exposure was total LOT, represented by the sum of estimated inpatient and observed outpatient LOT, and defined as “longer” if >9.5 days and “shorter” if ≤9.5 days. The outcome, post-discharge CDI, was defined using ICD-9-CM diagnosis code 008.45 in inpatient, skilled nursing, or outpatient claims within 6 months after index hospitalization. CDI 12 months before or during index hospitalization was excluded. CDI risk was assessed through a multivariable logistic model stratified by outpatient antibiotic class and adjusted for confounders including comorbidities, severity via ICU status, demographics, and hospital characteristics.ResultsThe cohort consisted of 99,883 patients. Median total LOT was 9.5 days (IQR: 7.4–11.4). Antibiotics filled at discharge included quinolones (40%), none (20%), multiple (14%), cephalosporins (10%), macrolides (7%), and β-lactam/β-lactamase inhibitor combinations (5%). CDI risk was 1.2%. Overall adjusted risk among those with longer LOT was 1.2 (95% CI: 1.1–1.4) times that of those with shorter LOT. Increased risk was observed among those prescribed quinolones at discharge, for whom adjusted CDI risk for longer LOT was 1.4 (95% CI: 1.2–1.7) times the risk of those with shorter LOT. We observed no difference in risk between longer and shorter LOTs for other antibiotic categories.ConclusionThese findings suggest that decreased LOT, which can be achieved with better adherence to current treatment guidelines, could reduce risk of subsequent CDI among patients hospitalized with CAP, particularly among those treated with fluoroquinolones at discharge.Disclosures All authors: No reported disclosures.

Ceftobiprole medocaril for the treatment of community-acquired pneumonia

ABSTRACTIntroduction: Ceftobiprole is a novel broad-spectrum cephalosporin with excellent activity against a broad range of pathogens that are important in community-acquired pneumonia (CAP), including drug-resistant pneumococci, methicillin-resistant Staphylococcus aureus, and Pseudomonas aeruginosa.Areas covered: This article reviews the spectrum of activity, the main pharmacological and pharmacodynamic characteristics of ceftobiprole as well its clinical efficacy and safety in the treatment of CAP in adult patients.Expert opinion: Taking into account that the current treatment guidelines for CAP recommend the use of an adequate empirical therapy to improve its prognosis, ceftobiprole shows a profile of antimicrobial activity that would cover most etiological agents in patients with risk factors for infection caused by multidrug resistant organisms. The results of the pivotal clinical trial of patients hospitalized with CAP treated with ceftobiprole showed a high rate of clinical cure. The clinical tolerance of ceftobiprole in clinical trials was generally very good. These findings make ceftobiprole a good parenteral therapeutic alternative for the empirical treatment of CAP that requires hospitalization, especially in patients with risk factors for CAP caused by resistant microorganisms.

Treatment guidelines for community-acquired pneumonia

Published guidelines for community-acquired pneumonia (CAP) have informed management and treatment recommendations for 25 years. Since inception, CAP guidelines have been developed for nearly every region of world, in part owing to improved mortality, clinical outcomes, and costs associated with implementation of guideline based care. This review highlights reasons why guidelines remain useful, overviews the similarities and differences among global CAP guidelines, and focuses on the treatment principles underpinning management recommendations, and addresses treatment issues that should be resolved in future CAP guidelines.

Community-acquired pneumonia: why aren't national antibiotic guidelines followed?

Adherence to guidelines for the management of community-acquired pneumonia (CAP) has been shown to improve patients' clinical outcomes. This study aimed to assess adherence to the Australian Therapeutic Guidelines (TG14) for the empirical management of CAP, and explore the potential barriers affecting adherence to these guidelines. Medical records were reviewed for all patients who were diagnosed with CAP within 24h of presentation at the Royal Hobart Hospital, the main teaching hospital in Tasmania, Australia, between July 2010 and March 2011. A survey of emergency department and medical team prescribers was also undertaken to identify potential barriers to adhere with the guidelines. χ(2) and Fisher's exact tests were used to test the significance between categorical data. To compare categorical and scale data, the Mann-Whitney U-test was used. A total of 193 patient records were assessed. The overall adherence to TG14 for the empirical antibiotic management of CAP was 16.1% (3.1%, 20.7% and 25.4% for patients with mild, moderate and severe CAP, respectively). Ceftriaxone was prescribed to 34.4%, 26.8% and 57.4% of patients with mild, moderate and severe CAP, respectively. The response rate to the barrier survey was 43.1%; of those who responded, 46.4% thought the influence of senior doctors on junior doctors could be a factor affecting adherence to the guidelines. Other barriers noted were a lack of guideline awareness (39.3%), the requirement to calculate the severity of CAP (35.7%), and the existence of other guidelines that conflict with TG14 (28.6%). Adherence to CAP treatment guidelines was poor, especially in patients with mild disease. Prescribing was mainly influenced by senior doctors. Efforts to improve compliance with CAP treatment guidelines should consider the potential barriers that hinder adherence.

PO-0010 The Physicians Approach To Community-acquired Pneumonia In Childhood

Background and aims Diagnosis and treatment guidelines for community-acquired pneumonia (CAP) are prepared to avoid differences for the diagnosis and management of CAP between physicians. We investigated the approaches of physicians to diagnosis, laboratory findings, treatment and the compatibility with guidelines for CAP. Method A total of 322 doctors were interviewed face to face and a 12 item-questionary incluiding diagnosis, investigation, treatment criteria and drug choices was filled by the physician. Results Contrarily to the guidelines 6.9% of physicians preferred auscultation and chest radiographygraphy (CXR) and did not use the symptoms for diagnosis. Only 11.8% preferred symptoms and diagnostic investigations. 58.8% did not use CXR, CBC and CRP, 24.5% did not use CXR, CBC, CRP and ERS and 4.9% of them did not prefer any investigations. Also routine CXR to confirm CAP in outpatient setting children is not recommended by guidelines physicians preferred CXR at high percentage. Physicians did not preferred Amoksisilin for mild CAP between 3 months - 2 years old children, 55% preferred parenteral treatment with ampisilin/sulbactam. Parenteral Seftriakson was preferred for hospitalised patients (>5 years) with severe pneumonia. 49.7% of physicians preferred ten day duration of therapy, 17.1% stopped treatment after disappearance of symptoms and auscultation findings, 13.7% completed the treatment after improvement of CXR. Conclusion Physicians applied different approaches to the diagnosis and treatment of CAP in infants and children. According to our findings, we suggested that physicians should be educated about approaches for treatment of CAP according to guidelines.

Searching for the Optimal Treatment of Ceftriaxone-Resistant Streptococcus pneumoniae in Community-Acquired Pneumonia

Ceftriaxone-resistant Streptococcus pneumoniae (CRSP) (minimal inhibitory concentration > 1 mcg/mL) is a growing major concern in the optimal selection of empirical antimicrobial treatment of community-acquired pneumonia (CAP). It has been estimated that up to 37.9% of S. pneumoniae are resistant to ceftriaxone in the United States in 2012,1 with a mean of 19.2% in Europe including greater than 25% in Eastern Europe (Bulgaria, Romania, and Turkey) in 20112 and 18.5% in China in 2011.3 This high rate of CRSP has been in part correlated with the introduction of the PCV7 in 2001 and of PCV13 in 2010 and the selection of serotypes 19A, 6C, and 22F.4,5 The increasing use of antimicrobials in humans and in food-producing animals among others is expected to contribute to the rising rate of CRSP.6 Mutation of cell wall penicillin-binding protein (PBP), particularly PBP1a, PBP2x, and PBP2b, was associated with CRSP.7 Because S. pneumoniae is the most common etiologic agent of CAP, physicians should optimize the empirical therapy of CAP in areas with a high rate of CRSP. Wenzler et al8 examined in this issue the clinical outcomes of patients with CRSP (minimal inhibitory concentration > 1 mcg/mL) versus ceftriaxone-susceptible S. pneumoniae in adult patients with pneumonia and respiratory culture positive for S. pneumoniae. Regardless of the sample size limitation, this study has striking findings. None of the patients with CRSP infection had 90 days of previous exposure of ceftriaxone. Time to clinical cure was longer in patients with CRSP (4 [1–5] vs 8 [3–12] days, P = 0.51), and length of stay was longer for patients with CRSP (17 [9–23] vs 9 [7–13] days, P = 0.46). The empirical treatment was changed in 50% of the patients with CRSP infection versus 0% in those with ceftriaxone-susceptible pneumoniae infection. A 50% of patients with CRSP infection were treated with fluoroquinolones, and 70% were treated with either vancomycin or linezolid. Among other findings, 70% of the patients with CRSP infection had pneumonia severity index of IV or greater. Overall, both groups had similar clinical outcomes although these outcomes may not have been similar if patients with CRSP infection were treated with ceftriaxone according to CAP treatment guidelines. Large prospective studies are needed to validate the optimal treatment of CRSP CAP. Current options for the treatment of CRSP CAP are fluoroquinolones, vancomycin, linezolid, and ceftaroline. Ceftaroline is the first of the growing group of active cephalosporins against methicillin-resistant Staphylococcus aureus and it also has activity against CRSP. Ceftaroline showed sustained bactericidal activity against CRSP in a pharmacokinetics and pharmakodynamics model study.9 This ceftaroline activity was validated in a rabbit model at a simulated human dose of 20 mg/kg by reducing 6 log units of CRSP in the lungs.10 Furthermore, a second analysis of studies focus 1 and 2 revealed that patients with S. pneumoniae CAP treated with ceftaroline had more favorable outcome than patients treated with ceftriaxone (odds ratio, 2.6; 95% confidence interval, 1.11–6.17; P = 0.0286).11 An approach in the empirical therapy of CRSP CAP could be a similar strategy used for bacterial meningitis by adding vancomycin to ceftriaxone treatment. Current Infectious Diseases Society of America guidelines do not recommend the use of vancomycin in cases with severe CAP nor CRSP. Vancomycin has a limited bactericidal activity when compared with β-lactams. Although levofloxacin and moxifloxacin have effective activity against CRSP, fluoroquinolones use has been reported to trigger higher rates of multiple drug resistance Pseudomonas, methicillin-resistant Staphylococcus aureus, and Clostridium difficile infections.12 In contrast to linezolid, ceftaroline has a spectrum similar to ceftriaxone covering gram-negative rods, including those etiologic organisms of CAP such as Klebsiella spp., Haemophilus spp., and Moraxella. In summary, physicians should consider antimicrobials with activity against CRSP in patients with CAP residing in areas with substantial prevalence of CRSP, in particular, those from the US southern states, having history of previous antibiotic therapy, and being immunocompromised.1,6 This concern is critical in patients with advanced comorbidities and increased risk for poor outcomes. Current data support more the use of ceftaroline treatment in cases with suspected CRSP pneumonia. Physicians should be cautious to use fluoroquinolones treatment of CRSP infection given the risk for antimicrobial resistance. Other treatment options include vancomycin although it has limited bactericidal activity compared with β-lactams and linezolid, which has the advantage of 100% of intestinal absorption that makes it a candidate for oral therapy.

Community-Acquired Pneumonia with Risk for Drug-Resistant Pathogens

Pneumonia is a leading infectious cause of morbidity and mortality in the United States. The Infectious Disease Society of America (IDSA) and American Thoracic Society (ATS) have published treatment guidelines for community-acquired pneumonia (CAP) based upon the site of acquisition and specific pathogen risk. The literature demonstrates improved outcomes with guideline-concordant empiric therapy. A subset of patients with CAP has risk factors for drug-resistant pathogens (DRPs). IDSA/ATS treatment guidelines do not provide clear recommendations for empiric treatment, and clinical studies have not provided descriptive data for this group. A retrospective chart review of all admissions between January 1, 2008 and April 19, 2009 with an International Classification of Diseases-9 code and physician-documented diagnosis of pneumonia at two community hospitals were performed. IDSA pneumonia type and presence of risk factors for DRP were recorded for each patient, and the empiric antibiotic therapy received was evaluated. Admissions were excluded if immunosuppression or pregnancy was present. Of the 400 admissions reviewed, 343 patients were included. A total of 228 patients (71%) had CAP. Forty-three percent of patients with CAP had risk factors for DRP. Only 2% of this group received an antibiotic regimen with coverage of the specific DRP risk factor present. The most common DRPs not receiving coverage in this group were Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus. P. aeruginosa and methicillin-resistant S. aureus occurred more commonly in culture-positive patients with CAP with DRP risk factors but did not achieve statistical significance. A larger sample size would be needed to determine whether this difference is significant. Risk factors for DRP occurred commonly in our CAP population. Patients with CAP with risk for DRP may be a distinct group who are without clear guidance on treatment. Future studies are needed to define the risk of DRP and the impact upon empiric therapy for patients with CAP.

Impact of infectious etiology on the outcome of Taiwanese patients hospitalized with community acquired pneumonia

This study aimed to assess the relationships between infectious etiology, empiric treatment, and outcomes in Taiwanese patients with community acquired pneumonia (CAP). A retrospective analysis of the data of 208 adult patients from a single medical center was performed with patients classified as having low or high disease severity based on the Pneumonia Severity Index (PSI). Patients with PSI ≤ 90 (n=120) were classified as low severity and patients with PSI > 90 (n=88) were classified as high severity. The low-risk group had significantly higher rates of infection with Chlamydia pneumoniae (C. pneumoniae) and Mycoplasma pneumoniae (M. pneumoniae), whereas the high-risk group had significantly higher rates of infection with Klebsiella pneumoniae (K. pneumoniae) and Pseudomonas aeruginosa (P. aeruginosa) (p < 0.05). Empiric treatment in both groups was in accordance with the 2007 guidelines issued by the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS). Twenty-nine of 208 patients (13.9%) died, one in the low-risk group and 28 in the high-risk group. The highest rates of mortality were in patients infected with P. aeruginosa or K. pneumoniae. In the present study, we demonstrated that the patients with different severity had different microbiologic etiology. In general, P. aeruginosa and K. pneumoniae were the most commonly isolated organisms in high-risk patients who died from CAP. We showed that use of the IIDSA/ATS guidelines for treatment of CAP in Taiwan resulted in a better outcome in the low PSI group.

A 2011-2012 Survey of Doctors' Perceptions of Korean Guidelines and Empirical Treatment of Community-Acquired Pneumonia

BackgroundThe causative pathogens of and prevalence of antibiotic resistance in community-acquired pneumonia (CAP) varies across countries. We evaluated the patterns of antibiotic prescriptions for adult CAP patients, and physician satisfaction with the form and content of the 2009 Korean CAP treatment guidelines.Materials and MethodsWe designed an online survey for clinical physicians who treat CAP (infectious disease specialists, pulmonologists, and other physicians). We e-mailed the online survey to physicians and gathered results from December 2011 to January 2012, and then analyzed their responses.ResultsA total of 157 physicians responded to our survey: 61 (38.9%) infectious disease specialists, 33 (21.0%) pulmonologists, and 63 (40.1%) other physicians. Two-thirds (96/157, 61.2%) had positions in tertiary and secondary hospitals; the others (61, 38.8%) worked in primary clinics (hospitals and private clinics). One hundred and eight (68.8%) were aware of the Korean CAP clinical guidelines; of these, 98 (62.4%) applied the guidelines to their practice. Among physicians using them, 86.7% (85/98) reported the guidelines to be most useful for empirical selection of antibiotics, and 75.2% (118/157) said the guidelines were useful and satisfactory. Sixty-eight (43.3%) respondents indicated that they had not used aminoglycosides as an initial empirical CAP treatment, while 51 (32.5%) had combined aminoglycosides with other antibiotics to treat patients with CAP. Seventy-three (46.5%) physicians often combined macrolides with β-lactam antibiotics for empirical treatment of CAP, and 21 (13.4%) reported using macrolide monotherapy (which is not recommended in the 2009 Korean CAP treatment guidelines) for CAP patients. The most commonly used β-lactams were third-generation cephalosporins (72, 45.9%) and ampicillin/sulbactam or amoxicillin/clavulanate (28, 17.8%).ConclusionsSome physicians remain unaware of the 2009 Korean treatment guidelines for CAP and do not use them in clinical practice. In addition, aminoglycoside combination therapy is frequently and inappropriately used in practice. In some cases, CAP is treated with macrolide monotherapy. Thus, the Korean CAP clinical guidelines must be more aggressively and continuously publicized.

Ambulatory Visit Rates and Antibiotic Prescribing for Children With Pneumonia, 1994–2007

The incidence of pediatric hospitalizations for community-acquired pneumonia (CAP) has declined after the widespread use of the heptavalent pneumococcal conjugate vaccine. The national incidence of outpatient visits for CAP, however, is not well established. Although no pediatric CAP treatment guidelines are available, current data support narrow-spectrum antibiotics as the first-line treatment for most patients with CAP. To estimate the incidence rates of outpatient CAP, examine time trends in antibiotics prescribed for CAP, and determine factors associated with broad-spectrum antibiotic prescribing for CAP. The National Ambulatory and National Hospital Ambulatory Medical Care Surveys (1994-2007) were used to identify children aged 1 to 18 years with CAP using a validated algorithm. We determined age group-specific rates of outpatient CAP and examined trends in antibiotic prescribing for CAP. Data from 2006-2007 were used to study factors associated with broad-spectrum antibiotic prescribing. Overall, annual CAP visit rates ranged from 16.9 to 22.4 per 1000 population, with the highest rates occurring in children aged 1 to 5 years (range: 32.3-49.6 per 1000). Ambulatory CAP visit rates did not change between 1994 and 2007. Antibiotics commonly prescribed for CAP included macrolides (34% of patients overall), cephalosporins (22% overall), and penicillins (14% overall). Cephalosporin use increased significantly between 2000 and 2007 (P = .002). Increasing age, a visit to a nonemergency department office, and obtaining a radiograph or complete blood count were associated with broad-spectrum antibiotic prescribing. The incidence of pediatric ambulatory CAP visits has not changed significantly between 1994 and 2007, despite the introduction of heptavalent pneumococcal conjugate vaccine in 2000. Broad-spectrum antibiotics, particularly macrolides, were frequently prescribed despite evidence that they provide little benefit over penicillins.

Community Acquired Pneumonia

Community-acquired pneumonia (CAP) is a major cause of morbidity, of mortality, and of expenditure of medical resources. The etiology and antimicrobial susceptibility of CAP pathogens can differ by country. Treatment guidelines need to reflect the needs of individual countries based on pathogen susceptibility studies. Recent treatment guidelines for CAP in Korea were published by the Joint Committee of the Korean Academy of Tuberculosis and Respiratory Diseases, the Korean Society for Chemotherapy, and the Korean Society of Infectious Diseases. In this article, the etiologies, diagnoses, treatments for CAP will be reviewed and compared to the recent published Korean guidelines for CAP treatment.

Compliance With ATS-IDSA Guideline Recommendations for Empiric Antibiotic Therapy in Pneumonia

PURPOSE: The ATS and IDSA have jointly authored treatment guidelines for community-acquired pneumonia (CAP), healthcare-associated pneumonia (HCAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP). Little data exist regarding guideline compliance and the consequences of non-compliant regimens.

Treatment Guidelines for Community-acquired Pneumonia in Korea: An Evidence-based Approach to Appropriate Antimicrobial Therapy

*지역사회획득 폐렴 치료지침 제정위원회의 공동 위원장. † 지역사회획득 폐렴 치료지침 제정위원회의 자문위원. 지역사회획득 폐렴 치료지침 제정위원회의 위원. § 현 소속: 한국보건의료연구원(National Evidence-based Healthcare Collaborating Agency). 본 치료지침 권고안은 대한화학요법학회, 대한감염학회, 대한결핵 및 호흡기학회가 공동으로 위원회를 구성하여 최신 국내외 근거를 검토하고 논의를 거쳐 개발되었고, 상기 학회의 인증을 거쳐 제정되었으며 대한개원내과의사회의 검토를 거쳤음. 본 치료지침 권고안은 기본적인 원칙을 제시하는 것으로서 모든 환자에 대해서 일률적으로 적용하는 것보다는 지침을 기본적으로 참고하되 개개 환자의 여러 상황을 고려한 의사의 최종적인 판단이 중요함. 이 과제는 질병관리본부 학술연구용역사업으로 수행한 결과임(과제번호: 2008-E00174-00). Address for correspondence: Jae-Hoon Song, M.D., Ph.D. Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Asian-Pacific Research Foundation for Infectious Diseases (ARFID), 50, Ilwon-dong, Gangnam-gu, Seoul 135-710, Korea Phone: 82-2-3410-0320, Fax: 82-2-3410-0328, E-mail: songjh@skku.edu or jhsong@ansorp.org Received: Sep. 11, 2009 Accepted: Sep. 22, 2009 DOI: 10.4046/trd.2009.67.4.281 ISSN: 1738-3536(Print)/2005-6184(Online) Tuberc Respir Dis 2009;67:281-302 CopyrightC2009. The Korean Academy of Tuberculosis and Respiratory Diseases. All rights reserved.

Hospital visits and costs following outpatient treatment of CAP with levofloxacin or moxifloxacin

Background:Hospital admissions (inpatient and emergency room) are a major source of medical costs for community-acquired pneumonia (CAP) initially treated in the outpatient setting. Current CAP treatment guidelines do not differentiate between outpatient treatment with levofloxacin and moxifloxacin.Objective:Compare health care resource use and medical costs to payers for CAP outpatients initiating treatment with levofloxacin or moxifloxacin.Research design and methods:CAP episodes were identified in the PharMetrics database between 2Q04 and 2Q07 based on: pneumonia diagnosis, chest X-ray and treatment with levofloxacin or moxifloxacin. Subsequent 30-day risk of pneumonia-related hospital visits and 30-day health care costs to payers for levofloxacin vs. moxifloxacin treatment were estimated after adjusting for pre-treatment demographics, health care resource use and pneumonia-specific risk factors using propensity score and exact factor matching.Results:A total of 15,472 levofloxacin- and 6474 moxifloxacin-initiated CAP patients were identified. Among 6352 matched pairs, levofloxacin treatment was associated with a 35% reduction in the odds of pneumonia-related hospital visits (odds ratio = 0.65, P = 0.004), lower per-patient costs for pneumonia-related hospital visits ($102 vs. $210, P = 0.001), lower pneumonia-related total costs (medical services and prescription drugs, $363 vs. $491, P < 0.001) and lower total costs ($1308 vs. $1446, P < 0.001) vs. moxifloxacin over the 30-day observation period.Limitations:Although observational analyses of claims data provide large sample sizes and reflect routine care, they do have several inherent limitations. Since randomization of subjects is not possible, adequate statistical techniques must be used to ensure that patient characteristics are well-balanced between treatment groups. In addition, data may be missing or miscoded.Conclusions:CAP outpatients initiated with levofloxacin generated substantially lower costs to payers compared to matched patients initiated with moxifloxacin. The cost savings for patients initiated with levofloxacin were largely attributable to reduced rates of pneumonia-related hospitalization or ER visits.

Predicting Positive Blood Cultures in Patients presenting with Pneumonia at an Emergency Department in Singapore

Routine blood cultures have been recommended for all patients in treatment guidelines for community-acquired pneumonia (CAP). This practice has become a major area of resource utilisation, despite the lack of evidence in its clinical utility. Calls for abandoning the practice is balanced by the occasions of uncovering an unexpected pathogen or an unusual antimicrobial resistance pattern. The aim of this study is to identify factors that predict positive blood cultures among patients hospitalised for pneumonia upon presentation at the Emergency Department (ED). A case control study was carried out on patients treated for pneumonia in the ED who had routine blood cultures performed as part of their management. The pneumonia severity index (PSI) was used to categorize patients into low- and high-risk for 30-day mortality. Logistic regression was carried out to determine factors significantly associated with positive blood cultures, from which a predictive probability equation was used to identify patients whose blood cultures were negative at a pre-determined cut-off, with minimum number of culture positive misclassification. A scoring system was devised, with scores predicting which patients would be likely to have a positive or negative blood culture. A total of 1407 patients with pneumonia were treated at ED from May to December 2006, from whom 1800 blood cultures were performed. Of these, 140 cultures (7.8%) grew organisms, comprising 96 (5.3%) true positive cultures and 44 (2.4%) contaminated cultures. Logistic regression analysis identified ill patients with higher PSI classes, smokers and Malay patients to be more likely to have positive blood cultures. Patients who had prior treatment with antibiotics, chronic obstructive pulmonary disease and cough were less likely to have positive blood cultures. An index to predict a negative blood culture resulted in the accurate classification of all but 4 positive patients while still correctly classifying 27.8% of blood culture negative patients. The area under the ROC curve was 0.71 (95% CI, 0.65-0.76). A simplified scoring system was devised based on the predictive model had a sensitivity of 82% and specificity of 38.2% for a positive blood culture. Routine blood cultures yielded negative results in 94% of patients presenting with pneumonia. The development of the clinical scoring system is a first step towards selecting patients for whom blood cultures is performed and improve cost-effectiveness.

Treatment Guidelines for Community-acquired Pneumonia in Korea: An Evidence-based Approach to Appropriate Antimicrobial Therapy

The successful treatment of community-acquired pneumonia requires appropriate, empirical antimicrobial therapy. The etiology and antimicrobial susceptibility of major pneumonia pathogens can differ by country. Therefore, the ideal treatment guidelines for community-acquired pneumonia should be based on the studies performed in each country. We developed a treatment guideline for community-acquired pneumonia for immunocompetent adults in Korea. This guideline was developed by the joint committee of the Korean Society for Chemotherapy, the Korean Society of Infectious Diseases, and the Korean Academy of Tuberculosis and Respiratory diseases.

Treatment Guidelines for Community-acquired Pneumonia in Korea: An Evidence-based Approach to Appropriate Antimicrobial Therapy

The successful treatment of community-acquired pneumonia requires appropriate, empirical antimicrobial therapy. The etiology and antimicrobial susceptibility of major pneumonia pathogens can differ by country. Therefore, the ideal treatment guidelines for community-acquired pneumonia should be based on the studies performed in each country. We developed a treatment guideline for community-acquired pneumonia for immunocompetent adults in Korea. This guideline was developed by the joint committee of the Korean Society for Chemotherapy, the Korean Society of Infectious Diseases, and the Korean Academy of Tuberculosis and Respiratory diseases.

Empiric treatment in hospitalized community-acquired pneumonia. Impact on mortality, length of stay and re-admission

To evaluate adherence to guidelines when choosing an empirical treatment and its impact upon the prognosis of community-acquired pneumonia (CAP). A prospective multicentre study was conducted in 425 CAP patients hospitalized on ward. Initial empirical treatment was classified as adhering or not to Spanish guidelines. Adherent treatment was defined as an initial antimicrobial regimen consisting of beta-lactams plus macrolides, beta-lactam monotherapy and quinolones. Non-adherent treatments included macrolide monotherapy and other regimens. Initial severity was graded according to pneumonia severity index (PSI). The end point variables were mortality, length of stay (LOS) and re-admission at 30 days. Overall 30-day mortality was 8.2%, the mean LOS was 8+/-5 days, and the global re-admission rate was 7.6%. Adherence to guidelines was 76.5%, and in most cases the empirical treatment consisted of beta-lactam and macrolide in combination (57.4%). Logistic regression analysis showed that other regimens were associated with higher mortality OR=3 (1.2-7.3), after adjusting for PSI and admitting hospital. Beta-lactam monotherapy was an independent risk factor for re-admission. LOS was independently associated with admitting hospital and not with antibiotics. A high adherence to CAP treatment guidelines was found, though with considerable variability in the empirical antibiotic treatment among hospitals. Non-adherent other regimens were associated with greater mortality. Beta-lactam monotherapy was associated with an increased re-admission rate.