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.

Reference

1. BTS CAP guidelines

2. RJ Oakey, V Slade. Physiological observation track and trigger system. Nursing Standard. 2006;20:48–54