Effects of guideline-concordant antimicrobial therapy on mortality among patients with community-acquired pneumonia

doi:10.1016/j.amjmed.2004.06.028

The American Journal of Medicine

Volume 117, Issue 10, 15 November 2004, Pages 726-731

https://doi.org/10.1016/j.amjmed.2004.06.028 Get rights and content

Abstract

Purpose

National practice guidelines have recommended specific initial empiric antimicrobial regimens for patients with community-acquired pneumonia. Our aim was to determine the association between the use of guideline-concordant antimicrobial therapy and 30-day mortality in patients with pneumonia.

Methods

We conducted a retrospective cohort study at two tertiary teaching hospitals. Eligible patients were admitted with a diagnosis of community-acquired pneumonia, had a chest radiograph consistent with pneumonia, and had a discharge diagnosis of pneumonia. All eligible patients were identified and a random sample was abstracted. We determined whether the use of guideline-concordant antibiotics was associated with 30-day mortality in an analysis that adjusted for potential confounders using propensity scores.

Results

Information was obtained on 420 patients with pneumonia. The mean (± SD) age was 63 ± 16 years, 355 were men, and 82 patients were initially admitted to the intensive care unit. At 30 days after presentation, 41 patients (9.8%) had died: 21 of 97 (21.7%) in the non–guideline-concordant group and 20 of 323 (6.2%) in the guideline-concordant group. Antibiotics were concordant with national guidelines in 323 patients. In the regression analysis, after adjustment for the propensity score, failure to comply with antimicrobial therapy guidelines was associated with increased 30-day mortality (odds ratio = 5.7; 95% confidence interval: 2.0 to 16.0).

Conclusion

Receipt of antimicrobial regimens concordant with national published guidelines may reduce 30-day mortality among patients hospitalized with pneumonia. Am J Med. 2004;117:726 -731.

Section snippets

Study sample

The sample included patients hospitalized at two academic tertiary care hospitals (one Veterans Affairs hospital and one county-run hospital) in San Antonio, Texas, between January 1, 2000, and December 31, 2001. Patients were identified using International Classification of Diseases, Ninth Revision (ICD-9) discharge diagnoses consistent with community-acquired pneumonia: a primary discharge diagnosis of pneumonia (codes 480.0–483.99; 485–487.0), or a primary diagnosis of respiratory failure

Results

Data were abstracted on 420 patients (Table 1). The mean (± SD) age of the cohort was 63 ± 16 years; 85% were men. Seventy-eight percent of patients were admitted through the emergency department, and 20% were admitted to the ICU within the first 24 hours after admission. Mortality was 9.8% (n = 41) at 30 days and 13.8% (n = 58) at 90 days. The mean length of hospital stay was 8.1 ± 9.1 days. Regarding pneumonia-related processes of care, 78% of patients received antibiotics within 8 hours of

Discussion

Community-acquired pneumonia continues to be an acute medical problem and is associated with substantial mortality and morbidity. Our study supports the hypothesis that the use of empiric antimicrobial therapy concordant with national clinical practice guidelines is associated with decreased mortality among patients hospitalized with community-acquired pneumonia, even after adjusting for other potential confounders. Patients who received nonconcordant antimicrobial therapy had an increased risk

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Colombian consensus on quality in intensive care: task force of the Colombian Association of Critical Medicine and Intensive Care (AMCI®)
2023, Acta Colombiana de Cuidado Intensivo
Para Colombia, es importante adoptar un sistema estandarizado y estructurado de gestión de la calidad para el mejoramiento continuo de la atención en salud en las unidades de cuidados intensivos (UCI). La Asociación Colombiana de Medicina Crítica y Cuidados Intensivos (AMCI) desarrolló este documento consenso para ofrecer recomendaciones en los distintos pilares de calidad en salud que son necesarios para la práctica dentro de las unidades. Fue construido con un enfoque integral, teniendo en cuenta la experiencia acumulada de los actores que ejercen la disciplina de la medicina crítica junto con el análisis de la mejor evidencia científica disponible, pero contextualizada a la perspectiva nacional. Este consenso busca garantizar y priorizar las condiciones de seguridad y calidad para los pacientes críticamente enfermos en las unidades. En respuesta a la variabilidad en procesos, sistemas, estructura y complejidad en las UCI de todo el territorio nacional, la AMCI convocó un equipo multidisciplinario de expertos en medicina crítica, clínicos y metodólogos para hacer un pronunciamiento científico mediante la metodología de consenso formal, principalmente por el método Delphi, acerca de los estándares de calidad necesarios para garantizar la eficiencia y calidad en los servicios de cuidados intensivos y que se puedan reflejar en los desenlaces de los pacientes. Se pretende impactar positivamente en los distintos niveles del sistema de salud, prestadores, administradores y aseguradores. También se pretende establecer canales de trabajo con el gobierno nacional y sus entes reguladores, para brindar argumentos desde la sociedad científica que puedan facilitar la formulación de políticas en normatividad de control y auditoría. El consenso invita a todas las UCI del país a realizar una autoevaluación de sus condiciones específicas, teniendo en cuenta los contenidos de este consenso, aclarando que fue desarrollado en un contexto científico, académico y no comercial, centrado en la búsqueda continua del beneficio para los pacientes, pero también del talento humano que labora en las unidades. Cada institución de salud debe ser garante mediante el liderazgo de la coordinación asistencial de las UCI de contar con las mejores condiciones para poder desarrollar la práctica de la medicina crítica. Este documento consenso se constituye una fuente para los procesos de mejoramiento. Este documento tiene un alcance nacional y su contenido está previsto de actualización en un tiempo no mayor a cuatro años.
For Colombia, it is important to adopt a standardized and structured quality management system for the continuous improvement of health care in intensive care units (ICU). The Colombian Association of Critical Medicine and Intensive Care (AMCI) developed this consensus document to offer recommendations on the different pillars of health quality that are necessary for practice within the units. It was built with a comprehensive approach, taking into account the accumulated experience of the actors who practice the discipline of critical medicine together with the analysis of the best available scientific evidence, but contextualized to the national perspective. This consensus seeks to guarantee and prioritize safety and quality conditions for critically ill patients in the units. In response to the variability in processes, systems, structure, and complexity in ICU throughout the national territory, the AMCI convened a multidisciplinary team of experts in critical medicine, clinicians, and methodologists to make a scientific statement using the consensus methodology. formally, mainly through the DELPHI method, about the quality standards necessary to guarantee efficiency and quality in intensive care services and that can be reflected in patient outcomes. It is intended to have a positive impact on the different levels of the health system, providers, administrators and insurers. It is also intended to establish work channels with the national government and its regulatory bodies, to provide arguments from the scientific society that can facilitate the formulation of policies in control and audit regulations. The consensus invites all intensive care units in the country to carry out a self-assessment of their specific conditions, taking into account the contents of this consensus, clarifying that it was developed in a scientific, academic and non-commercial context, focused on the continuous search for benefit for patients, but also for the human talent that works in the units. Each health institution must be a guarantor, through the leadership of the care coordination of the ICU, of having the best conditions to be able to develop the practice of critical medicine. This consensus document constitutes a source for improvement processes. This document has a national scope and its content is expected to be updated in no more than 4 years.
Impact of Cirrhosis on Pneumonia-Related Outcomes in Hospitalized Older Veterans
2019, American Journal of the Medical Sciences
Prior research has demonstrated high mortality rates in patients with cirrhosis who contract bacterial infections. The purpose of our study was to explore clinical outcomes such as 90-day mortality, rehospitalization, and intensive care unit (ICU) admission in older veterans with pneumonia and cirrhosis.
We conducted a retrospective cohort study of hospitalized patients with community-acquired pneumonia at any Departments of Veterans Affairs (VA) hospital over a 10-year period. We included patients 65 years or older who consistently received VA care and who were diagnosed with community-acquired pneumonia. There were 103,997 patients who met the inclusion criteria, and 1,246 patients with cirrhosis. We used multilevel regression models to examine the association between cirrhosis and the outcomes of interest after controlling for potential confounders.
Cirrhosis was associated with significantly increased odds of 90-day mortality (odds ratio 1.79, 95% confidence interval, 1.57-2.04). There were also significantly increased odds of rehospitalization within 90-days (1.30, 1.16-1.47). No significant association was found with ICU admission (1.00, 0.83-1.19).
We found an association between cirrhosis and 90-day mortality and rehospitalization in older patients with pneumonia. We suggest that physicians should carefully monitor patients with cirrhosis who develop pneumonia.
Degree of adherence to recommended antiviral treatment during the pandemic and post-pandemic periods of influenza A(H1N1)pdm09 in 148 intensive care units in Spain
2015, Medicina Intensiva
Evaluar el grado de adherencia a las recomendaciones sobre el tratamiento antivírico y su impacto en la mortalidad de pacientes críticos afectados por gripe A (H1N1)pdm09.
Análisis secundario de estudio prospectivo.
Medicina intensiva (UCI).
Pacientes con gripe A (H1N1)pdm09 en el periodo pandémico 2009 y pospandémico 2010-11.
La adherencia a las recomendaciones se clasificó en: total (AT), parcial dosis (PD), parcial tiempo (PT) y no adherencia (NA). La neumonía vírica, obesidad y ventilación mecánica fueron considerados criterios de gravedad para el uso de dosificaciones elevadas de antivírico (CG). Análisis mediante «chi» cuadrado y t-test. Supervivencia mediante regresión de Cox.
Se incluyeron 1.058 pacientes, 661(62,5%) en pandemia y 397 (37,5%) en pospandemia. La AT global del estudio fue del 41,6% (el 43,9% y el 38%, respectivamente; p = 0,07). Los pacientes con criterios de gravedad no fueron diferentes en ambos periodos (un 68,5% y un 62,8%; p = 0,06). En estos pacientes la AT fue del 54,7% durante el 2009 y del 36,4% en pospandemia (p < 0,01). La NA (19,7% vs. 11,3%; p < 0,05) y la PT (20,8% vs. 9,9%; p < 0,01) fueron más frecuentes durante la pospandemia. La mortalidad fue mayor en la pospandemia (30% vs. 21,8%; p < 0,001). El APACHE II(HR = 1,09) y la enfermedad hematológica (HR = 2,2) se asociaron a mortalidad y la adherencia (HR = 0,47) fue un factor protector.
Se evidencia un bajo grado de adherencia al tratamiento en ambos periodos. La adherencia al tratamiento antivírico se asocia con menor mortalidad y debería ser recomendada en pacientes críticos afectados por gripe A (H1N1)pdm09.
To determine the degree of antiviral treatment recommendations adherence and its impact to critical ill patients affected by influenza A(H1N1)pdm09 mortality.
Secondary analysis of prospective study.
Intensive care (UCI).
Patients with influenza A(H1N1)pdm09 in the 2009 pandemic and 2010-11 post-Pandemic periods.
Adherence to recommendations was classified as: Total (AT); partial in doses (PD); partial in time (PT), and non-adherence (NA). Viral pneumonia, obesity and mechanical ventilation were considered severity criteria for the administration of high antiviral dose. The analysis was performed using t-test or «chi» square. Survival analysis was performed and adjusted by Cox regression analysis.
A total of 1,058 patients, 661 (62.5%) included in the pandemic and 397 (37.5%) in post-pandemic period respectively. Global adherence was achieved in 41.6% (43.9% and 38.0%; P = .07 respectively). Severity criteria were similar in both periods (68.5% vs. 62.8%; P = .06). The AT was 54.7% in pandemic and 36.4% in post-pandemic period respectively (P < .01). The NA (19.7% vs. 11.3%; P < .05) and PT (20.8% vs. 9.9%, P < .01) was more frequent in the post-pandemic period. The mortality rate was higher in the post-pandemic period (30% vs. 21.8%, P < .001). APACHE II (HR = 1.09) and hematologic disease (HR = 2.2) were associated with a higher mortality and adherence (HR = 0.47) was a protective factor.
A low degree of adherence to the antiviral treatment was observed in both periods. Adherence to antiviral treatment recommendations was associated with lower mortality rates and should be recommended in critically ill patients with suspected influenza A(H1N1)pdm09.
Guidelines for the probabilistic treatment of community-acquired pneumonia: Compared experience between internal medicine and emergency departments in the University Hospital of Besançon, France
2014, Revue de Medecine Interne
Le but de ce travail était de comparer l’application du référentiel local (rédigé par la commission des médecins anti-infectieux de l’établissement) et national (recommandations de la Société de pathologie infectieuse de langue française [SPILF] de 2006 sur la prise en charge des infections respiratoires basses) dans la prise en charge des pneumopathies aiguës communautaires (PAC) non documentées dans un service de médecine interne où un référent en antibiothérapie est désigné et dans un service d’urgences d’adultes sans référent en antibiothérapie.
Il s’agit d’une étude rétrospective monocentrique portant sur des patients admis pour une PAC non sévère et non documentée dans le service de médecine interne du CHU de Besançon via le service d’urgences adultes.
Cent dossiers (58 femmes et 42 hommes) ont été examinés. L’âge moyen était de 79 ± 11 ans. Les prescriptions du service d’urgences adultes étaient conformes aux recommandations locales ou de la SPILF dans 62 % des cas alors qu’elles étaient conformes aux recommandations dans 94 % des cas dans le service de médecine interne (p < 0,05). L’absence de traitement initial au service des urgences adultes n’a pas eu d’influence en termes de morbi-mortalité.
Dans cette étude, les recommandations des sociétés savantes sont significativement plus souvent appliquées dans un service où un référent est désigné pour cette action.
The objective of this study was to assess the application of local and national recommendations in the management of community-acquired pneumonia in an internal medicine department with an antibiotic referent physician and in an emergency department.
This was a retrospective single-center study including patients admitted with community-acquired pneumonia in the internal medicine department of the University Hospital of Besançon after an initial admission in the emergency department.
One hundred patients (58 women and 42 men) were included. The mean age was 79 ± 11 years. The prescriptions done in the emergency department were in accordance with local recommendations or Société de pathologie infectieuse de langue française (SPILF) recommendations in 62% of cases. The prescriptions followed the recommendations in 94% of cases in internal medicine department (P < 0.05). The lack of initial antibiotic treatment had no influence on morbidity and mortality.
The guidelines for infectious diseases treatment were significantly more often applied in a department where a referent physician was designated for this.
Evaluating the quality of antimicrobial prescribing: Is standardisation possible?
2013, Enfermedades Infecciosas y Microbiologia Clinica
Citation Excerpt :
Some studies have shown that adherence to guidelines results in shorter stays and lower mortality. In several studies on community-acquired pneumonia, adherence to the guidelines was an independent protective factor against treatment failure and death.35,36 There are other studies of hospital-acquired pneumonia, ventilator-associated pneumonia, meningitis and sepsis showing similar results: a reduction in antimicrobial use and costs, an increase of initial administration of adequate antimicrobial therapy, a shorten of therapy duration and a decrease of mortality.37–39
The quality of antimicrobial prescribing refers to the optimal way to use antibiotics in regard to their benefits, safety (e.g., resistance generation and toxicity) and cost. Evaluating the quality of antimicrobial prescribing in a way that focuses not only on reducing antimicrobial consumption but also on using them in a more optimal way allows us to understand patterns of use and to identify targets for intervention. The lack of standardisation is the primary problem to be addressed when planning an evaluation of antimicrobial prescribing. There is little information specifically describing an evaluation methodology. Information related to prescription evaluation can be obtained from the guidelines of Antimicrobial Stewardship Programs (ASPs) and from local and international experience. The criteria used to evaluate the quality of prescription should include the indication for antimicrobial therapy, the timeliness of initiation, the correct antibiotic choice (according to local guidelines), the dosing, the duration, the route of administration and the time at which to switch to oral administration. A locally developed guideline on antimicrobial therapy should preferably be the gold standard by which to evaluate the appropriatenes of prescriptions.
Various approaches used to carry out the evaluations have been described in the literature. Repeated point-prevalence surveys (PPS) have been proven to be effective in identifying targets for quality improvement. Continuous prospective monitoring allows the identification of more precise intervention points at different times during prescription. The design of the study chosen to perform the evaluation should be adapted according to the resources available in each centre. Evaluating the quality of antimicrobial prescribing should be the first step to designing ASPs, as well as to evaluating their impact and the changes in prescribing trends over time.
La calidad de la prescripción de antibióticos se refiere a la forma óptima de usar antibióticos en relación con sus beneficios, seguridad (p. ej., generación de resistencia y toxicidad) y coste. La evaluación de la calidad de la prescripción de antibióticos de forma que se centre no solo en la reducción del consumo de antibióticos, sino también en su uso de una forma más óptima nos permite comprender los patrones de uso e identificar las dianas para la intervención. La ausencia de estandarización es el principal problema que debe ser resuelto cuando se planifica una evaluación de la prescripción de antibióticos. Existe poca información que describa específicamente una metodología de evaluación. La información relacionada con la evaluación de la prescripción puede obtenerse de las guías de los programas de optimización de uso de antibióticos (PROA) y de la experiencia local e internacional. Los criterios utilizados para evaluar la calidad de la prescripción deberían incluir la indicación para terapia antimicrobiana, el momento del inicio, la selección correcta del antibiótico (de acuerdo con las guías locales), la dosis, la duración, la vía de administración y el momento en el que se cambia a administración oral. Es preferible una guía sobre el tratamiento antibiótico desarrollada localmente para ser utilizada como gold standard en la evaluación de lo apropiado de las prescripciones.
Han sido descritos en la literatura varios planteamientos utilizados para llevar a cabo las evaluaciones. Las encuestas de prevalencia puntual (EPP) repetidas han demostrado ser eficaces para identificar las dianas de la mejora de la calidad. El control prospectivo continuo permite la identificación de puntos de intervención más precisos en diferentes momentos durante la prescripción. El diseño del estudio seleccionado para realizar la evaluación debe ser adaptado de acuerdo con los recursos disponibles en cada centro. La evaluación de la calidad de la prescripción de antibióticos debe ser el primer paso para diseñar PROA, así como evaluar su impacto y los cambios en las tendencias de prescripción a lo largo del tiempo.
Adherence between antibiotic prescriptions and guidelines in an internal medicine ward: An evaluation of professional practices
2013, Revue de Medecine Interne
Il s’agit d’une évaluation des pratiques professionnelles (EPP) sur l’antibiothérapie dans un service de médecine interne.
Un recueil prospectif sur six mois des prescriptions antibiotiques et leur comparaison avec les recommandations locales et nationales (molécule, dose journalière, modalité d’administration, durée) ont été réalisés.
Deux cent vingt-sept antibiothérapies ont été recueillies. Par rapport aux recommandations locales, on retrouvait 56 % de schémas totalement respectés (STR) (infections bronchopulmonaires [IBP] : 38 %, urinaires : 88 % et cutanées : 73 %), 33 % de schémas partiellement respectés (SPR) et 11 % de schémas différents (SD). En prenant comme référentiel les recommandations nationales relatives aux IBP, les résultats étaient : STR : 81 % (dont IBP : 80 %), SPR : 16 %, et SD : 3 %.
Ce retour sur les prescriptions a permis de mettre en place des actions pérennes d’amélioration des pratiques. Cette démarche anticipe les EPP qui seront nécessaires pour l’accréditation des établissements et souligne l’intérêt de la prise en compte de plusieurs sources de recommandations pour l’interprétation des résultats.
This is an evaluation of professional practices (EPP) on antibiotic therapy in an internal medicine ward.
A 6-month prospective review of antibiotic prescriptions and their comparisons with local and national guidelines (drug, daily dose, administration, and duration) were performed.
Antibiotic therapy on 227 infectious episodes was collected. According to local guidelines, we found 56% of totally respected (lower respiratory tract infections: 38%, urinary tract infections: 88% and skin infections: 73%), 33% of partially respected and 11% of non-appropriate prescriptions. Considering national guidelines for lower respiratory tract infections as references, the results were: totally respected prescriptions 81%, partially respected prescriptions 16%, and non-appropriate prescriptions 3%.
This evaluation of the prescriptions allowed setting up long-lasting actions to improve clinical practice. This approach anticipates the procedures of EPP that will be needed for hospital accreditation and highlights the importance of considering several guidelines for the interpretation of the results.

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¹: Dr. Mortensen was supported by a Howard Hughes Medical Institute faculty start-up grant (00378-001) and a Department of Veteran Affairs Veterans Integrated Service Network 17 new faculty grant. Dr. Pugh was supported by a Department of Veteran Affairs grant (HFP98-002). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

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Clinical studiesEffects of guideline-concordant antimicrobial therapy on mortality among patients with community-acquired pneumonia

Abstract

Purpose

Methods

Results

Conclusion

Section snippets

Study sample

Results

Discussion

Chest

Deathsfinal data for 1999

Natl Vital Stat Rep

Assessing prognosis and predicting patient outcomes in community-acquired pneumonia

Semin Respir Infect

Guidelines for the management of community-acquired pneumonia in adults admitted to the hospital

Br J Hosp Med

Guidelines for the management of community-acquired pneumonia in adults. Italian Society of Pneumology. Italian Society of Respiratory Medicine. Italian Society of Chemotherapy

Monaldi Arch Chest Dis.

Guidelines for the initial management of adult with community-acquired pneumoniadiagnosis, assessment of severity, and initial antimicrobial therapy

Am Rev Respir Dis

Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention

Am J Respir Crit Care Med.

Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America

Clin Infect Dis

Clinical studies
Effects of guideline-concordant antimicrobial therapy on mortality among patients with community-acquired pneumonia