Antibiotic Stewardship to Address Overtreatment in Community-Acquired Pneumonia

Patients with community-acquired pneumonia (CAP) were frequently given >10 days of antibiotics when a 5- to 7-day treatment regimen is as clinically effective, according to a study presented at ID Week 2016 in New Orleans, Louisiana. A shorter therapy course has a lower risk of adverse effects for patients and highlights an opportunity for antibiotic stewardship in CAP treatment.¹

Using retrospective analysis, Thomas L. Walsh, MD, of the Division of Infectious Diseases at Allegheny General Hospital and Western Pennsylvania Hospital in Pittsburgh, and colleagues examined length of antibiotic treatment in 98 patients 18 years of age and older admitted to either hospital with a diagnosis of CAP between March 1 and October 31, 2014.

Patient mean age was 64±17 years. Forty-five patients were men, 73 were white, 21 were black, and 4 were reported as other races. Chronic lung disease was noted in 53 patients, 15 of whom required the use of oxygen at home.

The researchers examined the duration of antibiotic treatment in patients with uncomplicated CAP and found that 26% received the clinically effective treatment for 5 to 7 days (the duration of which has been determined to be clinically effective).  Approximately 39% received >10 days of antibiotic treatment, which Dr Walsh and colleagues described as “concerning.”

Secondary outcomes studied included length of intravenous therapy (mean 4.9 days), duration of inpatient stay (mean 4.5 days), and 30-day all-cause readmission rate (14%).

The researchers also studied the frequency and results of diagnostic tests. Of 50% of patients whose sputum was collected for culture, 18% contained pathogens. Blood cultures were obtained in 88% of patients, but no pathogens were identified in those samples. Bronchoscopy with bronchoalveolar lavage was done in 14% of patients, with 2% identifying pathogens.

Of pathogens identified by diagnostic testing, 21% were Pseudomonas aeruginosa, 32% were Streptococcus pneumoniae (21% found as a urinary antigen and 11% in sputum), 14% were Beta-hemolytic streptococcus, 11% were Staphylococcus aureus, 7% were Legionella pneumophila (found as urinary antigen), and 4% were Stenotrophomonas maltophilia and  Escherichia coli, respectively.

After the rate of antibiotic use above the clinically effective treatment of 5 to 7 days was observed, the researchers created a bundled initiative for their Antibiotic Stewardship Program (ASP). Dr Walsh and colleagues held educational lectures to inform all medical staff from residents through top-tier practitioners in the hospital system about treatment guidelines. Next, they created an institutional CAP clinical decision-making algorithm distributed to medical and house staff via their yearly Antimicrobial Guide available in both print and electronic format. Lastly, the ASP team performed a CAP patient audit in real time with immediate oral responses to advised changes in management.

Briana DiSilvio, MD, from the Division of Infectious Diseases at Allegheny General Hospital and Western Pennsylvania Hospital in Pittsburgh, and co-author of the study told Infectious Disease Advisor that, “Given the rising plague of antimicrobial resistance, strategies to limit the utilization of our limited armamentarium of antimicrobial agents are greatly needed. Given their breadth of effect and significant impact on morbidity and mortality, multidrug resistant bacteria are considered one of the largest threats to public health and national security by numerous prominent organizations including the Institute of Medicine, the Center for Disease Control Task Force on Antimicrobial Resistance, and the Infectious Diseases Society of America.”

“In its 2013 annual report on global risks,” she continued, “the World Economic Forum concluded that ‘arguably the greatest risk…to human health comes in the form of antibiotic-resistant bacteria.’”² Our study demonstrates that the management of hospitalized patients with CAP represents a significant opportunity to optimize the utilization of antibiotics. We hope to show that implementation of a syndrome-specific intervention via utilization of an ASP guided bundled approach represents a practical approach to dramatically reduce antimicrobial use by reducing the duration of therapy in addition to promoting the use of narrow spectrum therapy.”

Reference

1. Walsh TL, DiSilvio BE, Speredelozzi D, et al. Evaluation of management of community acquired pneumonia prior to implementation of an antimicrobial stewardship program initiative: a retrospective assessment. Presented at: IDWeek 2016. New Orleans, LA; October 26-30, 2016. Poster 1024.
2. Insight Report: Global Risks 2013, Eighth Edition. World Economic Forum. http://www3.weforum.org/docs/WEF_GlobalRisks_Report_2013.pdf Accessed December 14, 2016.