Pharmacology
Prospective evaluation of the treatment and outcome of community-acquired pneumonia according to the Pneumonia Severity Index in VHA hospitals

Presented in part at the 40th Interscience Conference on Antimicrobial Agents and Chemotherapy, September 17, 2000, Toronto, Canada.
https://doi.org/10.1016/j.diagmicrobio.2005.10.007Get rights and content

Abstract

The objective of the study were to determine if nationally recognized community-acquired pneumonia (CAP) guidelines (specific to antibiotic therapy) were being followed and to identify outcomes of treatment in hospitals that are VHA members. This was a prospective study using a medication use evaluation in an inpatient setting conducted in 46 institutions in the United States during the 1998–1999 CAP season. The subjects were 875 adult patients (≥18 years of age) admitted from the emergency department or ambulatory care setting with a chest X-ray–confirmed diagnosis of CAP. Treatment pathways were in place in 58.7% (27/46) of institutions, with 18.3% of patients treated according to pathways. Twenty-seven percent of patients were PSI class I or II. A pathogen (blood or sputum) was identified in <10% of patients. The first dose of antibiotic was administered to patients 65% of the time in the emergency department. Antibiotic therapy in 592 of the 694 admitted to a general medical unit (mortality rate, 3%) complied with 1998 Infectious Diseases Society of America (IDSA) guidelines compared with 26 of the 65 admitted to the intensive care unit (ICU) (mortality rate, 4.6%). In patients admitted to other nongeneral medical, non-ICU areas, IDSA guidelines were followed in 95% of the patients. Mean length of stay and mortality for PSI classes I–V were 4.5, 4.6, 6.9, 6.2, and 7.1 days, respectively, and 0%, 0.7%, 1.1%, 2.5%, and 10.5%, respectively. Antibiotic therapy was modified in 733 of 875 patients. Approximately 90% of patients were eligible for conversion to oral (per os) therapy before discontinuation of parenteral (intravenous) antibiotics (mean time to eligibility, 1.8 days of parenteral antibiotics), with conversion in 65% (mean time to conversion to oral therapy, 4.6 days). Resolution of CAP occurred in 92% of patients; deterioration was more common in PSI class IV and V patients. In conclusion, inhospital mortality rates for all PSI classes were similar to those found in other recently conducted studies despite limited adherence to pathways. Greater use of treatment guidelines for patients admitted to the ICU and awareness of the intravenous to per os antibiotic conversion process are suggested.

Introduction

Community-acquired pneumonia (CAP) affects nearly 3 million people every year and results in more than 900 000 physician visits on a monthly basis (Centers for Disease Control and Prevention, 1997, Marston et al., 1997). It is also responsible for 500 000 hospitalizations and more than 40 000 deaths annually in the United States alone (Centers for Disease Control and Prevention, 1997, Marston et al., 1997). Mortality among hospitalized patients with CAP can reach 30% versus less than 1% in patients not hospitalized (Fine et al., 1996, Fine et al., 1997) In addition to the mortality and morbidity of CAP, the annual cost to the health care system is billions of dollars (Medicare and Medicaid statistical supplement, 1995, Dans et al., 1984, La Force, 1985, Niederman et al., 1998). Fine et al. (1997) developed a prediction rule (Pneumonia Severity Index [PSI]) comprised of 5 risk classes with increasing mortality rates, indicating outpatient care for patients in classes I and II, short inpatient observational period for class III patients, and standard inpatient treatment of all patients in classes IV and V. When this prediction rule has been used on CAP data collected from 1991 to 1994 in hospitalized patients, the overall all-cause mortality within 30 days for each risk class was as follows: I, 0.1%; II, 0.6%; III, 2.8%; IV, 8.2%; and V, 29.2% (Fine et al., 1997).

With the advent of new antibacterials and the understanding that rapid institution of antibiotic therapy in patients with CAP reduces mortality (Meehan et al., 1997), the therapy for CAP has evolved. Two professional societies, the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS), have issued guidelines concerning selection of antibiotics for empiric treatment of CAP (Bartlett et al., 1998, Niederman et al., 2001, Bartlett et al., 2000). The guidelines from IDSA also include recommendations for the use of oral therapy in patients who are improving clinically, hemodynamically stable, and able to ingest oral medication with a functioning gastrointestinal tract. A medication use evaluation (MUE) for CAP during November 1998–March 1999 CAP season was coordinated by the Pharmacy Clinical Solutions team of Novation, the supply company of VHA, and the University Hospitals Consortium (UHC) to determine whether the nationally recognized CAP guidelines were being followed and what those outcomes of treatment were. The VHA and UHC are 2 networks of hospitals that have combined their buying power together in efforts to reduce supply expenditures to member organizations. The specific objectives for this evaluation included collection of prospective data on patients with CAP during the 1998–1999 pneumonia season; stratification of data on patients with CAP according to level of risk; determination of whether appropriate antibiotic selection and timing of antibiotic administration occurred based on the 1998 IDSA CAP guidelines; determination of whether laboratory and diagnostic tests were used appropriately; assessment of modification of antibiotic selection, route of administration, and duration of therapy; and comparison of outcomes of various treatment modalities and risk levels for CAP.

Section snippets

Study design

This was a prospective study conducted in 46 institutions across the United States during November 1998–March 1999 in patients hospitalized with the diagnosis of CAP. Consecutive adult patients (≥18 years of age) admitted from the emergency department or ambulatory care setting with a chest X-ray–confirmed diagnosis of CAP were included. Patients excluded from the study included residents of nursing homes or long-term care facilities; patients with witnessed or probable aspiration;

Results

Forty-six hospitals participated in this CAP MUE with a total of 875 patients evaluated. No hospital reported data on less than 5 patients. Information on the institutions participating in the MUE is shown in Table 3. Patient demographics and clinical information are presented in Table 4, and the PSI for patients is shown in Table 5.

Discussion

The results of this study demonstrated a similar in-hospital mortality rate for PSI classes II–V as compared with results from another recently conducted trial (Bratzler et al., 2001) (0.7%, 1.1%, 2.5%, and 10.5%, respectively, in our study versus 0.4%, 1.3%, 5.0%, and 17.9% in the study conducted by Bratzler et al., 2001). Bratzler et al. (2001) retrospectively evaluated a random sample of 750 Medicare patients (≥65 years of age) to describe if there is an association between timing/selection

Conclusions

Our study was conducted in 46 institutions and showed a similar in-hospital mortality rate for all PSI classes, as compared with findings of a recently conducted trial with similar study population (Bratzler et al., 2001), and a lack of adherence to national CAP guidelines (with respect to admission decisions, time to antibiotic delivery, selection of antibiotic regimens, and timely conversion to oral therapy). Based on available literature, a multidisciplinary approach to the treatment of

References (52)

  • R.E. Siegel et al.

    A prospective randomized study of inpatient IV antibiotics for community-acquired pneumonia. The optimal duration of therapy

    Chest

    (1996)
  • R. Theerthakarai et al.

    Nonvalue of the initial microbiological studies in the management of nonsevere community-acquired pneumonia

    Chest

    (2001)
  • G.W. Waterer et al.

    The influence of the severity of community-acquired pneumonia on the usefulness of blood cultures

    Respir. Med.

    (2001)
  • G.W. Waterer et al.

    The impact of blood cultures on antibiotic therapy in pneumococcal pneumonia

    Chest

    (1999)
  • S.J. Atlas et al.

    Safely increasing the proportion of patients with community-acquired pneumonia treated as outpatients: an interventional trial

    Arch. Intern. Med.

    (1998)
  • J.G. Bartlett et al.

    Community-acquired pneumonia in adults: guidelines for management. The Infectious Diseases Society of America

    Clin. Infect. Dis.

    (1998)
  • J.G. Bartlett et al.

    Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America

    Clin. Infect. Dis.

    (2000)
  • D.S. Battleman et al.

    Rapid antibiotic delivery and appropriate antibiotic selection reduce length of hospital stay of patients with community-acquired pneumonia: link between quality of care and resource utilization

    Arch. Intern. Med.

    (2002)
  • R. Benenson et al.

    Effects of a pneumonia clinical pathway on time to antibiotic treatment, length of stay, and mortality

    Acad. Emerg. Med.

    (1999)
  • D.W. Bratzler et al.

    Initial processes of care and outcomes in elderly patients with pneumonia

  • Centers for Disease Control and Prevention

    Premature deaths, monthly mortality and monthly physician contacts: United States

    MMWR Morb. Mortal. Wkly. Rep.

    (1997)
  • R. Cregin et al.

    Multidisciplinary approach to improving treatment of community-acquired pneumonia

    Am. J. Health Syst. Pharm.

    (2002)
  • P.E. Dans et al.

    Management of pneumonia in the prospective payment era: a need for more clinician and support service interaction

    Arch. Intern. Med.

    (1984)
  • V. Dudas et al.

    Antimicrobial selection for hospitalized patients with presumed community-acquired pneumonia: a survey of nonteaching US community hospitals

    Ann. Pharmacother.

    (2000)
  • M.J. Fine et al.

    Prognosis and outcomes of patients with community-acquired pneumonia

    JAMA

    (1996)
  • M.J. Fine et al.

    A prediction rule to identify low-risk patients with community-acquired pneumonia

    N. Engl. J. Med.

    (1997)
  • Cited by (0)

    This study was supported by an unrestricted educational grant from Roche Laboratories.

    View full text