title: Targets for antibiotic and healthcare resource stewardship in inpatient community-acquired pneumonia: a comparison of management practices with National Guideline Recommendations.
abstract: OBJECTIVE
  Community-acquired pneumonia (CAP) is the most common infection leading to hospitalization in the USA. The objective of this study was to evaluate management practices for inpatient CAP in relation to Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guidelines to identify opportunities for antibiotic and health care resource stewardship.
  
  
  METHODS
  This was a retrospective cohort study of adults hospitalized for CAP at a single institution from 15 April 2008 to 31 May 2009.
  
  
  RESULTS
  Of the 209 patients with CAP who presented to Denver Health Medical Center during the study period and were hospitalized, 166 (79 %) and 43 (21 %) were admitted to a medical ward and the intensive care unit (ICU), respectively. Sixty-one (29 %) patients were candidates for outpatient therapy per IDSA/ATS guidance with a CURB-65 score of 0 or 1 and absence of hypoxemia. Sputum cultures were ordered for 110 specimens; however, an evaluable sample was obtained in only 49 (45 %) cases. Median time from antibiotic initiation to specimen collection was 11 [interquartile range (IQR) 6-19] h, and a potential pathogen was identified in only 18 (16 %) cultures. Blood cultures were routinely obtained for both non-ICU (81 %) and ICU (95 %) cases, but 15 of 36 (42 %) positive cultures were false-positive results. The most common antibiotic regimen was ceftriaxone + azithromycin (182, 87 % cases). Discordant with IDSA/ATS recommendations, oral step-down therapy consisted of a new antibiotic class in 120 (66 %), most commonly levofloxacin (101, 55 %). Treatment durations were typically longer than suggested with a median of 10 (IQR 8-12) days.
  
  
  CONCLUSIONS
  In this cohort of patients hospitalized for CAP, management was frequently inconsistent with IDSA/ATS guideline recommendations, revealing potential targets to reduce unnecessary antibiotic and healthcare resource utilization.
authors.affiliation: Department of Medicine, Denver Health Medical Center, 660 Bannock Street, Denver, CO, 80204, USA. timothy.jenkins@dhha.org
authors.forename: T C
authors.initials: TC
authors.lastname: Jenkins
authors.forename: S A
authors.initials: SA
authors.lastname: Stella
authors.forename: L
authors.initials: L
authors.lastname: Cervantes
authors.forename: B C
authors.initials: BC
authors.lastname: Knepper
authors.forename: A L
authors.initials: AL
authors.lastname: Sabel
authors.forename: C S
authors.initials: CS
authors.lastname: Price
authors.forename: L
authors.initials: L
authors.lastname: Shockley
authors.forename: M E
authors.initials: ME
authors.lastname: Hanley
authors.forename: P S
authors.initials: PS
authors.lastname: Mehler
authors.forename: W J
authors.initials: WJ
authors.lastname: Burman
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D017714:Community-Acquired Infections / Q000175:diagnosis* / Q000188:drug therapy*; D005260:Female; D006295:Health Resources; D006801:Humans; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000175:diagnosis* / Q000188:drug therapy*; D017410:Practice Guidelines as Topic; D011216:Practice Management, Medical / Q000592:standards; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents