Introduction Prompt appropriate antibiotics for community acquired pneumonia (CAP) reduces mortality, length of stay and adverse events. Antibiotic choice is directed by the CURB-65 score and clinical judgement.1 Admission is recommended for most CURB-65 ≥2.1 Recent national data showed an unexplained non-compliance of 40% (>2000 patients) with CAP antibiotic guidelines using CURB-65 scores alone. Antimicrobial misuse and resistance are a global concern. We investigated compliance with our Trust CAP guidelines and used an early warning score (EWS)2 to quantify clinical judgement.
Methods Data were collected retrospectively for adults attending the emergency department with CAP4 over 4 months. The CURB-65 and the Trust’s EWS (Physiological Observations Track and Trigger system – POTTS)2 were calculated at presentation. A POTTS score of 2 triggers escalation of care. Prescriptions were compliant when the initial antibiotic concurred with the Trust guideline. Patients receiving broader spectrum agents than recommended were ‘over-treated’. Admission was noted.
Results (Table 1) Of 77 patients with CAP, 11 (14%) received ‘compliant’ antibiotics (Table 1). 38 (49%) patients were over-treated, 25 (66%) of whom had POTTS ≥2, though 15 (60%) of these patients had low severity CURB-65 of 0–1. Of 49 patients with POTTS ≥2, 27 (55%) had a CURB-65 of 0–1, 26% a CURB-65 of 2. 44% and 68% of those with a CURB-65 of 0 or 1 were admitted, with higher average POTTS than those discharged.
Conclusion The majority of patients incorrectly prescribed broad spectrum antibiotics had a CURB-65 score that failed to categorise them as sick enough to warrant them despite an EWS≥2. Hospital admission demonstrated similar findings. Over half of those with an elevated EWS had a low severity CURB-65. We did not collect outcome data but the ‘over-treatment’ and admission appear appropriate. Prompt, effective and empiric antimicrobials for septic patients give better clinical outcomes. Seemingly non-compliant antimicrobial prescriptions may have punitive implications for Trusts. We suggest that CURB-65 under-recognises sepsis syndrome and thus the EWS should be included and further validated in CAP guidelines and audits.
BTS CAP guidelines
RJ Oakey, V Slade. Physiological observation track and trigger system. Nursing Standard. 2006;20:48–54