Background The recent British Thoracic Society national audit of community-acquired pneumonia (CAP) has shown that guideline concordance and antimicrobial stewardship remain poor in the UK. Furthermore, mis- and over-diagnosis are common.¹

Methods A Respiratory Infections Team was developed, comprising a specialist nurse supported by a respiratory consultant and antimicrobial pharmacist. Its aims were to review patients admitted to hospital with CAP, and to a) identify patients with low severity CAP for remote outpatient management with early supported discharge; b) facilitate streamlined antibiotic regimens using bedside point-of-care (POC) tests (BinaxNOW pneumococcal and legionella urinary antigens, and nasopharyngeal swab for influenza PCR), reducing total amount of antibiotic prescribed both in route and spectrum; and c) improve diagnostic accuracy, communication with clinical coders, and concordance with the BTS pneumonia care bundle. Outcomes were compared with a prospective cohort of consecutive radiographically-confirmed CAP admissions from winter 2013/2014.

Results Over the first year the team reviewed 351 patients with suspected CAP; 50 had a chest radiograph reported as clear and were excluded, leaving 301 for analysis. Length of hospital stay (LOS) was reduced when compared with pre-intervention after adjustment for disease severity using CURB-65 (low severity, 2.8 vs 4.4 days, p<0.01; moderate severity, 4.3 vs 7.6 days, p<0.01; high severity, 6.0 vs 8.9 days, p=0.07). Readmission rate at 30 days was unchanged (54/301, 17.9% vs. 50/324, 15.4%, p=0.45). Early supported discharge was appropriate in 51/172 (30.0%) patients with low severity CAP; in this group median LOS was 1.4 days and readmission rate 6/51 (11.8%). A positive microbiological diagnosis was made in 69/301 (22.9%) patients compared with 16/324 (4.9%) pre-intervention; 60/301 (19.9%) had a positive POC test with a result available within the acute admitting area. As a result, broad spectrum antibiotic regimens were streamlined in 43 (14.3%) patients.

Conclusion A dedicated respiratory infections team can significantly reduce LOS for patients admitted with CAP. A robust microbiological diagnosis early in the admission episode Results in an improvement in antibiotic stewardship.

Reference

1. Daniel P, Bewick T, Welham S, et al. Adults miscoded and misdiagnosed as having pneumonia: Results from the British thoracic society pneumonia audit. Thorax 2017;72(4):376–79.