title: Safety and efficacy of CURB65-guided antibiotic therapy in community-acquired pneumonia.
abstract: OBJECTIVE
  To determine whether the introduction of a community-acquired pneumonia (CAP) severity assessment tool to guide antibiotic selection could reduce broad-spectrum antibiotic prescribing without compromising patient safety.
  
  
  METHODS
  A prospective before and after evaluation study. Empirical antibiotic prescribing was studied for 18 months from June 2006 to January 2008 (pre-intervention) and then for 18 months following the implementation of a CURB65-guided antibiotic therapy guideline in June 2008. The primary outcome was the use of broad-spectrum antibiotics (cephalosporin, amoxicillin plus clavulanic acid and macrolides) in patients with CAP. Safety outcomes were 30 day mortality, requirement for mechanical ventilation and/or vasopressor support (MV/VS), development of complicated pneumonia, time to clinical stability (TCS) and length of hospital stay.
  
  
  RESULTS
  The introduction of CURB65-guided therapy resulted in an overall reduction in the prescription of cephalosporins (from 27.1% of patients receiving this agent in the overall pre-intervention cohort to 8.0% in the post-intervention cohort, P < 0.0001) and macrolides (72.8% to 58.7%, P < 0.0001), particularly among low-risk patients. There was a corresponding increase in the prescription of the narrower-spectrum agent amoxicillin (29.7% to 41.7%, P < 0.0001) and an increase in the use of amoxicillin monotherapy (10.4% to 29.9%, P < 0.0001). Co-amoxiclav use increased slightly as this agent replaced cephalosporins as first-line treatment for severe CAP. The guideline had no impact on 30 day mortality, MV/VS, complicated pneumonia, TCS or length of stay. Following the intervention, adherence to national guidelines increased from 25.4% of prescriptions to 61.9%, suggesting the potential for further improvements.
  
  
  CONCLUSIONS
  CURB65-guided antibiotic therapy was associated with a significant decrease in broad-spectrum antibiotic use. The intervention was safe with no impact on mortality, treatment failure or clinical response.
authors.affiliation: MRC Centre For Inflammation Research, Queens Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK.
authors.forename: James D
authors.initials: JD
authors.lastname: Chalmers
authors.forename: Aran
authors.initials: A
authors.lastname: Singanayagam
authors.forename: Ahsan R
authors.initials: AR
authors.lastname: Akram
authors.forename: Gourab
authors.initials: G
authors.lastname: Choudhury
authors.forename: Pallavi
authors.initials: P
authors.lastname: Mandal
authors.forename: Adam T
authors.initials: AT
authors.lastname: Hill
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000009:adverse effects / Q000627:therapeutic use*; D017714:Community-Acquired Infections / Q000188:drug therapy* / Q000401:mortality; D064420:Drug-Related Side Effects and Adverse Reactions; D005260:Female; D017408:Guidelines as Topic; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000188:drug therapy* / Q000401:mortality; D012720:Severity of Illness Index; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents