Changing Physician Prescribing Behavior: The Community-Acquired Pneumonia Intervention Trial

Kim C. Coley, Susan J. Skledar , Michael J. Fine, Donald M. Yealy , Patrick P. Gleason , Michael L. Ryan, Wishwa Kapoor , and Robert A. Branch

Disclosures

Am J Health Syst Pharm. 2000;57(16) 

In This Article

Pharmagram

Antimicrobial CAP treatment costs at UPMC are 2 to 3 times higher than at other similar institutions without a demonstrated benefit in clinical outcomes. These higher costs are driven by overprescribing of certain antimicrobials, such as ceftriaxone (Rocephin), piperacillin (Pipracil), ciprofloxacin (Cipro), ticarcillin/ clavulanate (Timentin), and ampicillin/sulbactam (Unasyn).

Cefuroxime is as effective as piperacillin, piperacillin/tazobactam (Zosyn), Timentin, ciprofloxacin, and Unasyn against common CAP bacterial pathogens (i.e., S. pneumoniae, H. influenzae), polymicrobials (including gram-positive anaerobes), most aerobic gram-negative bacilli, and S. aureus.

The UPMC Departments of Pharmacy, Internal Medicine, Emergency Medicine, and Infectious Disease recommend the following for empiric treatment of immunocompetent patients with nonsevere CAP (not requiring ICU admission) #:

  1. Cefuroxime 750 mg IV q 8 hours.

  2. If Legionella is suspected, erythromycin 500 mg IV q 6 hours may be added.


Cost Ratio†
Cefuroxime (Zinacef) 750 mg IV q8 hours $
Cefuroxime (Zinacef) 1.5 grams IV q8 hours $$
Ceftriaxone Sodium (Rocephin) 1 gram IV q24 hours $$
Ceftriaxone Sodium (Rocephin) 2 grams IV q24 hours $$$$
Ceftazidime (Ceftaz) 2 grams IV q8 hours $$$$$
Ampicillin/Sulbactam (Unasyn) 1.5 grams IV q6 hours $$
Ampicillin/Sulbactam (Unasyn) 3 grams IV q6 hours $$$$
Ciprofloxacin (Cipro) 400 mg IV q12 hours $$$
Ticarcillin/Clavulanate (Timentin) 3.1 grams IV q6 hours $$$$
Piperacillin Sodium (Pipracil) 4 grams IV q6 hours $$$$

†Based on UPMC preparation, administration, and antimicrobial acquisition costs
* Neutrophil count > 1000 cells/mm3 , no history of splenectomy, use of systemic corticosteroids 10 mg/day (prednisone equivalent) within 90 days, or myelosuppressive drug therapy within 90 days.
# Based on a modified version of the American Thoracic Society guidelines for empiric treatment of CAP. Am Rev Respir Dis. 1993; 1418-26.
FOR MORE INFORMATION, call your patient unit pharmacy or the Drug Information Center.

All the educational efforts took place over a two-month period beginning in August 1996. These measures were not repeated at any other time during the study. The Pyxis and chart reminders and the audit and feedback aspects of the program continued throughout the active intervention period from October 1996 to June 1997. During these nine months, patients admitted to the hospital with a preliminary diagnosis of CAP were identified for inclusion in the intervention group. Inclusion and exclusion criteria were identical to those for the control group. At the end of the intervention period, demographic, antimicrobial use, and outcome data were collected through the MARS and compared with the data for the control period.

Demographic data collected included age, sex, admission severity group (ASG) score, and ICD-9 codes. ASG scoring ranks the probability of death on a scale from 0 (lowest probability) to 4 (highest).[22] Other measures included (1) antimicrobials initially prescribed in the ED for patients admitted through the ED, (2) antimicrobials prescribed empirically on the inpatient units, (3) number of antimicrobials initially prescribed, (4) total cost (based on acquisition price) of all antimicrobials prescribed during the entire length of stay, (5) length of stay, (6) inhospital mortality rate, and (7) number of hospital readmissions within one month of discharge. A follow-up analysis was conducted at the end of the intervention period to ascertain whether there was a sustained impact on prescribing. Patients hospitalized from July 1, 1997, to February 28, 1998, who met the original criteria for the study were evaluated to determine whether the initial antimicrobial prescriptions on the inpatient units met the treatment guidelines.

All outcomes were compared between the control and intervention periods. Dichotomous variables, including antimicrobial drug selection, mortality rate, and readmissions, were compared by chi-square analysis. Baseline ASG scores were compared by the Mann-Whitney U test. Continuous variables, such as length of stay, were compared by an unpaired t test for independent samples. The a priori level of significance was set at 0.05.

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