Guideline Concordance in Managing Community-Acquired Pneumonia: Room for Improvement

Abstract

Objective

To assess contemporary concordance of inpatient management of community-acquired pneumonia (CAP) with guideline recommendations relating to use of severity assessment tools (SAT), antimicrobials and microbiological investigations.

Methods

A single-centre, retrospective audit involving patients admitted with CAP to medical inpatient units of a tertiary hospital between September 2019 and March 2020 using electronic medical record review. SAT scores were retrospectively calculated for all patients, and the appropriateness of interventions determined with reference to local guidelines.

Results

Of 200 patients of mean age 64 years, 58% were admitted to general medicine units and the remainder to other specialties. Treating clinicians recorded a SAT in 9% (18/200) of the patients, with calculated scores rating 58% of all cases as being mild. Antibiotic prescribing on admission was guideline-concordant in 16.0% of the patients, but significantly higher among patients with moderate-to-severe vs mild CAP (24% vs 10%; p=0.01). Step-down oral antibiotic prescribing was guideline-concordant in 39% of the patients, and significantly higher among younger (<65 years) vs older patients (51% vs 31%; p=0.006) and those with longer (>7 days) vs shorter length of stay (57% vs 34%; p=0.007). No significant differences in concordance were seen between different specialties. Among patients for whom blood cultures and sputum cultures were requested, only 2% (2/110) and 17% (15/86) respectively yielded a positive result.

Conclusion

This study suggests infrequent use of SATs, low guideline concordance for antibiotic prescribing, and the need for more selective use of blood cultures. Reasons underpinning inappropriate antibiotic prescribing and strategies for reversing it need to be identified.

Keywords:

• community-acquired pneumonia
• guideline concordance
• risk stratification
• microbiological investigations
• antibiotics

Disclosure

The authors report no conflicts of interest in this work.