Prolonged antibiotic use opens the door to the development of antibiotic resistance, superinfections, and the risk of Clostridium difficile infections.
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 ≤37.8oC, 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.
To improve the situation, the researchers embarked on a stewardship initiative. In a novel twist, the initiative was not carried out within the four walls of a single institution, but rather was a group effort involving Michigan Medicine in Ann Arbor, Froedtert Hospital in Milwaukee, Wisconsin, and Ochsner Medical Center in Jefferson, Louisiana.
The primary objective was to assess the impact of the multifaceted stewardship intervention on the duration of antibiotic therapy for CAP. Secondary outcomes were effects of the intervention on patient outcomes and compliance with the IDSA/ATS recommendations concerning treatment duration before (n=307) and after (n=293) the stewardship initiative was launched.
Patients were included if they had a diagnosis of CAP, age ≥18 years, and had been admitted to 1 of the 3 hospitals. The stringent exclusion criteria were intended to whittle out those with illnesses that compromised CAP diagnosis and treatment.
As part of the initiative, when a patient achieved the IDSA/ATS criteria, a pharmacist member of the antimicrobial stewardship team contacted the primary care personnel. This allowed the compliance with the guideline recommendation concerning treatment duration to be determined.
The patients in the group prior to initiation of the stewardship intervention (control group) and the intervention group were similar demographically, with the exceptions of increased prevalence of myocardial infarction and chronic pulmonary disease in the intervention group, and increase steroid use in the control group.
The length of antibiotic therapy was 5 to 6 days in most of the control group (96.4%) and the intervention group (92.4%). The initiative essentially fit the duration of therapy more into the first few days. Before the initiative, the therapy could be prolonged, with a median of 9 days duration. The median duration after the initiative was rolled out was 6 days following implementation (P < .001). Median excess antibiotic days were reduced from 3 to 1 (P < .001).
There were no differences in hospital readmission or death between the groups, and no case of C. difficile infection.
“Active disease-based stewardship strategies are labor-intensive and require daily dedicated antimicrobial stewardship team time and resources. The multicenter nature of our initiative allowed for pooling of resources and sharing of information and tools,” said Dr. Foolad.
Although the guideline concordance increased significantly, the majority of patients were still not receiving appropriate therapy. Steps that could improve this include follow-up recommendation on the last day of appropriate therapy, notes and alerts in the electronic medical record, and stop dates for antibiotic agents.
“Further evaluations into inter-hospital partnerships for stewardship efforts are worthwhile,” Dr. Foolad noted.
Farnaz Foolad: none
Oral Abstract Session: Thinking Beyond Your Hospital: Stewardship on a Broader Scale
A Multicenter Stewardship Initiative to Decrease Excessive Duration of Antibiotic Therapy for the Treatment of Community-Acquired Pneumonia. Farnaz Foolad, PharmD, The University of Texas MD Anderson Cancer Center, Houston, TX
Brian Hoyle, PhD, is a medical and science writer and editor from Halifax, Nova Scotia, Canada. He has been a full-time freelance writer/editor for over 15 years. Prior to that, he was a research microbiologist and lab manager of a provincial government water testing lab. He can be reached at email@example.com.