RESPIRATORY INFECTION

Reducing door-to-antibiotic time in community-acquired pneumonia: controlled before-and-after evaluation and cost-effectiveness analysis

Gavin Barlow¹, Dilip Nathwani¹, Fiona Williams², Simon Ogston², John Winter¹, Michael Jones¹, Peter Slane¹, Elizabeth Myers¹, Frank Sullivan², Nicola Stevens¹, Rebecca Duffey², Karen Lowden¹, Peter Davey²

¹ Ninewells Hospital and Medical School, Dundee, Scotland, UK
² University of Dundee, Dundee, Scotland, UK

Correspondence to:
G Barlow
Department of Infection and Tropical Medicine, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Cottingham, East Yorkshire, UK;gavin.barlow{at}hey.nhs.uk

Background: Practice guidelines suggest that all patients hospitalised with community-acquired pneumonia (CAP) should receive antibiotics within 4 h of admission. An audit at our hospital during 1999–2000 showed that this target was achieved in less than two thirds of patients with severe CAP.

Methods: An experienced multidisciplinary steering group designed a management pathway to improve the early delivery of appropriate antibiotics to patients with CAP. This was implemented using a multifaceted strategy. The effect of implementation was evaluated using a controlled before-and-after study design over two winter seasons (November–April 2001–2 and 2002–3). Cost-effectiveness analyses were performed from the hospital’s perspective.

Results: The proportion of patients receiving appropriate antibiotics within 4 h of admission to hospital increased from 33% to 56% at the intervention site, and from 32% to 36% at the control site (absolute change adjusted for differences in severity of illness 17%, p = 0.035). The cost per additional patient receiving appropriate antibiotics within 4 h was £132 with no post-implementation evaluation, and £456 for a limited post-implementation evaluation. Simple modelling from the results of a large observational study suggests that the cost per death prevented could be £3003 with no post-implementation evaluation, or £16 632 with a limited post-implementation evaluation.

Conclusions: The intervention markedly improved door-to-antibiotic time, albeit at considerable cost. It might still be a cost-effective strategy, however, to reduce mortality in CAP. Uncertainty about the cost effectiveness of such interventions is likely to be resolved only by a well-designed, cluster randomised trial.

Abbreviations: A&E, accident and emergency; AMAU, acute medical admissions unit; BTS, British Thoracic Society; CAP, community-acquired pneumonia; CURB65, confusion, urea, respiratory, blood pressure, age >65

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