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Adherence to clinical practice guidelines for treating hospitalized patients with CAP improves outcomes, two studies suggest

Tuesday, September 29 2009 | Comments

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What's This? Adherence to current clinical practice guidelines for treating inpatients with community-acquired pneumonia (CAP) leads to improved health outcomes and reduced resource utilization, according to the results of two recent studies.

In one investigation, researchers evaluated data from 113 facilities that were part of a large hospital network to assess whether the use of antimicrobial combinations as outlined in the 2007 Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guidelines was associated with improved survival and other clinical outcomes among 54,619 patients with CAP admitted to non-intensive care settings.

Among other recommendations, the IDSA/ATS guidelines outline initiating empirical antimicrobial therapy for all hospitalized patients with CAP using a broad-spectrum regimen. Among the records analyzed, 35,477 cases (65%) had received initial guideline-concordant therapy.

After controlling for several potential confounding factors, guideline-concordant treatment was associated with a decreased likelihood of in-hospital mortality (odds ratio [OR], 0.70; 95% CI, 0.63-0.77), sepsis (OR, 0.83; 95% CI, 0.72-0.96), and renal failure (OR, 0.79; 95% CI, 0.67-0.94). Such adherent therapy also led to a significant mean reduction in the length of stay (LOS) by 0.66 days (P<.001) and led to a more rapid discharge among those who received such treatment as compared with those who did not (hazard ratio, 1.12; 95% CI, 1.10-1.14).

The switch from parenteral to oral antibiotics also occurred an average of 0.57 days earlier with guideline-concordant treatment P<.001).

"Although clinical practice guidelines should never obviate the need to consider carefully the peculiarities of a given clinical scenario, our findings provide an additional support for such guidelines as a high-quality, default path of care for adults sufficiently ill to require non–intensive care unit hospitalization," the researchers concluded. (McCabe C, et al. Arch Intern Med 2009;169:1525-1531.)

The second investigation examined adherence to the 2007 IDSA/ATS guidelines and the effect this has on outcomes among elderly subjects in particular.

Researchers conducted a secondary analysis of data from the Community-Acquired Pneumonia Organization International Cohort Study. This analysis focused on 1,649 patients aged at least 65 years who were hospitalized with CAP. In all, 975 cases had been managed with guideline-concordant treatment.

The results showed that 71% of the patients treated according to the guidelines reached clinical stability--defined as meeting the criteria for switching from parenteral to oral therapy-- at 7 days compared with 57% treated with nonadherent therapy. In addition, LOS was significantly shorter with adherent treatment (median, 8 days; interquartile range [IQR], 5-15 days) as compared with nonadherent treatment (median, 10 days; IQR, 6-24 days; P<.01).

Overall in-hospital mortality was statistically significantly decreased with guideline-adherent treatment (P<.01).

"Although clinical judgment may indicate the need not to adhere to guidelines when caring for elderly patients with CAP, we recommend that empirical therapy with a spectrum of activity less than what is recommended by the 2007 IDSA/ATS guidelines be avoided," the researchers concluded. (Arnold FW, et al. Arch Intern Med 2009;169:1515-1524.)

In accompanying editorial, Dr. Bradley Sharpe suggests that while the current guidelines are not perfect, adherence to them should be promoted by health care systems. "[W]hile we await further research, patients hospitalized with CAP should receive treatment with guideline-concordant antibiotic regimens covering both typical and atypical organisms," he commented. (Arch Intern Med 2009;169:1462-1464.)

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