In the largest disease-based study involving community-acquired pneumonia (CAP) conducted to date, a stewardship initiative involving 3 hospitals significantly reduced the duration of therapy. In addition, the hospitals met the reduction target recommended in the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guideline in over 40% of cases with no compromised patient outcomes or safety.
“This multifaceted stewardship intervention was successful in improving the duration of antimicrobial therapy,” said Farnaz Foolad, PharmD,
the University of Texas MD Anderson Cancer Center, Houston, Texas.
However, the fact that the IDSA/ATS duration guideline was not met in about 60% of cases means there is still work left to be done.
Management of CAP and pneumonia-related performance measures have been bolstered by the Centers for Medicare and Medicaid Services regulations concerning reimbursement. Improvement efforts have involved disease identification, optimizing the start time of antibiotic therapy, culture acquisition, vaccination, and reducing the number of hospital readmissions. However, reducing the length of treatment has been left by the wayside.
The IDSA/ATS guideline recommends that before therapy is stopped, CAP patients need to be treated for at least 5 days, be fever-free for 48-72 hours, and have no more than 1 sign of CAP instability. The criteria for clinical stability are temperature ≤37.8o
C, heart rate ≤100 beats per minute, respiratory rate ≤24 breaths per minute, systolic blood pressure ≥90 mmHg, and arterial oxygen saturation ≥90% or pO2 ≥60 mmHg on room air.
A recent multicenter randomized trial involving more than 300 CAP patients validated the safety of the IDSA/ATS recommendations concerning the duration of therapy, with similar 10- and 30-day success for the control and IDSA/ATS groups. “In practice, however, compliance with the recommendations for duration of therapy appears to be suboptimal, resulting in an unnecessarily long antibiotic duration of therapy for CAP patients,” said Dr. Foolad.
Prolonged antibiotic use opens the door to the development of antibiotic resistance, superinfections, and the risk of Clostridium difficile
infections in CAP patients treated with third-generation cephalosporins or fluoroquinolones.