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Reducing door-to-antibiotic time in community-acquired pneumonia: controlled before-and-after evaluation and cost-effectiveness analysis
  1. Gavin Barlow1,
  2. Dilip Nathwani1,
  3. Fiona Williams2,
  4. Simon Ogston2,
  5. John Winter1,
  6. Michael Jones1,
  7. Peter Slane1,
  8. Elizabeth Myers1,
  9. Frank Sullivan2,
  10. Nicola Stevens1,
  11. Rebecca Duffey2,
  12. Karen Lowden1,
  13. Peter Davey2
  1. 1Ninewells Hospital and Medical School, Dundee, Scotland, UK
  2. 2University of Dundee, Dundee, Scotland, UK
  1. 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}


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.

  • 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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  • Published Online First 23 August 2006

  • Funding: This project was funded by NHS Education Scotland and The Chief Scientist Office, Scotland.

  • Competing interests: None.

  • Ethical approval: This project was approved by both Tayside University Hospitals NHS Trust’s medical ethics committee and Caldicot guardian.

    Contributors: GB was the project leader, chaired the steering group, collected and analysed the data and contributed to project design and drafts of the paper. FW and SO were involved in data handling and analysis throughout the project. DN, JW, MJ, PS, EM, FS, NS and RD were all members of the steering group and were involved in design and implementation of the quality improvement programme. KL was involved in implementation in the acute medical admissions unit and supplied the antibiotic costs data. PD designed the evaluation, supervised GB, oversaw all phases of the project and coauthored the paper. PD is the guarantor.

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