Practice Guideline Effective in Community-Acquired Pneumonia

Laurie Barclay, MD

February 21, 2012

February 21, 2012 — Use of a clinical practice guideline (CPG) for community-acquired pneumonia (CAP) led to increased use of ampicillin, which is appropriate first-line therapy for otherwise healthy children admitted with uncomplicated CAP, according to the results of a retrospective study reported in an article published online February 20 in Pediatrics.

"[CAP] is a common pediatric illness caused by Streptococcus pneumoniae," write Ross E. Newman, DO, from the Department of Pediatrics, University of Missouri–Kansas City School of Medicine, Children's Mercy Hospitals and Clinics, and colleagues. "New pediatric Infectious Diseases Society of America CAP guidelines are now available recommending ampicillin as empirical treatment of children hospitalized with uncomplicated CAP."

The study goal was to assess the effect of implementing a CPG on antibiotic treatment of children hospitalized with CAP. The study sample consisted of patients admitted to a children's hospital from July 8, 2007, through July 9, 2009, and discharged with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), code for pneumonia (480–486). This period began 12 months before and ended 12 months after introduction of the CAP CPG. The investigators used 3-stage least squares regression analyses to evaluate the effect of their institution's antimicrobial stewardship program (ASP) and other hypothesized simultaneous associations.

Of 1033 patients included in the final analysis, 530 (51%) were admitted before CPG implementation, and 503 (49%) were admitted after CPG implementation. The most commonly prescribed antibiotic before CPG implementation was ceftriaxone (72%), followed by ampicillin (13%); ampicillin was the most commonly prescribed antibiotic after CPG implementation (63%).

The effect of the CPG was associated with a 34% increase in ampicillin use, and the combined effect of the CPG and ASP was associated with a 12% increase in amoxicillin use at hospital discharge and a 16% decrease in cefdinir and amoxicillin/clavulanate use (P < .001 for all). During both study periods, treatment failure was infrequent (1.5% before CPG implementation and 1% after CPG implementation).

"A CPG and ASP led to the increase in use of ampicillin for children hospitalized with CAP," the study authors write. "In addition, less broad-spectrum discharge antibiotics were used. Patient adverse outcomes were low, indicating that ampicillin is appropriate first-line therapy for otherwise healthy children admitted with uncomplicated CAP."

There was less compliance with other guideline recommendations, however. Obtaining blood cultures in all hospitalized children, for example, was recommended by the CPG, but the rate of blood culture draws in this population remained the same before and after the CPG (56% vs 54%; P = .4).

Limitations of this study include retrospective chart review, use of ICD-9 codes to identify patients with suspected uncomplicated CAP, and failure of the analysis to capture patients who experienced treatment failure and sought care at other institutions or had primary care physicians expand antimicrobial coverage for continued symptoms.

"Because CAP is a common pediatric condition, the use of a narrow-spectrum agent is important in preventing the further development of antibiotic resistance," the study authors conclude. "Second, although providers were willing to follow CPG recommendations for empirical antibiotic choices, other recommendations were not followed, including length of therapy and obtaining blood cultures. Finally, CPGs should be continually monitored and evaluated to ensure successful implementation, utilization, and revisions when required."

Three of the study authors were supported by a grant from the Agency for Healthcare Research and Quality.

Pediatrics. Published online February 20, 2012. Abstract


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