Contents

Guideline

Pathway

Instruction
Sheet

Prediction
Model

References

Outcomes

Task Force

Last Update/
Next Update

Disclaimer

Objective:

To make recommendations regarding evidence based cost-effective treatment of community acquired pneumonia in hospitalized patients. The guideline applies to adult non-immunosuppressed patients (immunosuppressed defined as HIV disease, AIDS, ANC<1000, current or recent myelosuppressive or immunosuppressive drugs, or prednisone>5mg/day). Patients with aspiration pneumonia, hospital or nursing home-acquired pneumonia, cystic fibrosis or bronchiectasis, a current diagnosis of cancer, and patients in need of mechanical ventilation or with sepsis are excluded. Most critically ill CAP patients will meet the above exclusion criteria. The guideline, however, includes brief recommendations for initial antibiotic use in critically ill CAP patients admitted to the ICU.

Options:

The options considered for treatment included a variety of initial diagnostic tests, several intravenous (IV) antibiotic regimens, various discharge criteria, and many different oral antibiotic regimens for use after patient stabilization.

Outcomes:

The outcomes considered in reviewing literature relevant to the development of the guideline included in-hospital mortality, 30 day mortality, readmission rates, and cost of antibiotic therapy. After the guideline was implemented, this institution looked at the above outcomes, as well as length of stay, complication rates, and rates of compliance with the guideline.

Evidence:

This guideline is derived from several studies on CAP as well as local data on bacterial resistance patterns and spectrum of antibiotic activity. Included were studies on etiology, diagnostic testing in CAP, prognosis, and risk stratification applying to admission and discharge decisions. The evidence was reviewed by content experts and guideline recommendations were then made in committee format. Antimicrobial susceptibility data from 1996 and cost data from 1997 are recent additions.

Values:

Where data was insufficient for the expert panel to make evidence based decisions, a high value was placed on patient safety. For example, no randomized controlled trials exist to direct the initial antibiotic selection. A high value on safety dictated a broad spectrum antibiotic regimen for initial therapy incorporating local susceptibility data, and emphasizing adequate pneumococcal coverage.

Key Recommendations:

All patients should receive a chest x-ray and blood cultures. Sputum gram stain and culture are not sufficiently sensitive nor specific to aid in predicting an etiologic agent in non-intubated CAP patients. Therefore, these tests are not routinely recommended. Emperic antibiotic therapy should be given as soon as possible and should include IV Ceftriaxone with the possible addition of Erythromycin or Doxycycline in certain cases. Stable patients at low risk for complications should be switched to oral antibiotics by hospital day three. The choice of an oral antibiotic is individualized, with emphasis placed on adequate Pneumococcal coverage, side effect profile, and cost. Stable patients at low risk for complications should be discharged by hospital day four. All eligible patients should receive Pneumococcal and Influenza vaccination. A new addition to the guideline includes recommendations for initial therapy in critically ill CAP patients admitted to the ICU. These patients should have sputum gram stains and cultures sent from the ICU (preferably by tracheal aspirate.) Patients <40 y.o. should generally receive Vancomycin, Ceftazidime and Erythromycin. Patients >= 40 y.o. should generally receive Vancomycin and Ciprofloxacin. Patients at increased risk for pseudomonal or aspiration pneumonia should receive Vancomycin, Zosyn, and Ciprofloxacin. If microbiologic testing does not identify a likely etiologic agent, critically ill patients may be switched on day 2 or 3 to Ceftriaxone and Erythromycin or Ceftriaxone and po Erythromycin or Doxycycline if orals can be tolerated (oral Azithromycin can be substituted for patients intolerant of Erythromycin or Doxycycline).

Benefits, Harms and Costs:

The guideline was first introduced in July, 1995 and outcomes were assessed after 18 months. Compliance with guideline recommendations was excellent. 95% of patients admitted with CAP received the recommended antibiotics. There was a marked decrease in the ordering of diagnostic tests that are not recommended (i.e. sputum gram stain or culture.) There was a 20% reduction in length of stay and a 30% reduction in costs with no change in hospital mortality or readmission rates. The portion of the guideline pertaining to ICU patients is a recent addition and, therefore, not assessed in the above outcomes.