title: High variability among Emergency Departments in 3rd-generation cephalosporins and fluoroquinolones use for community-acquired pneumonia.
abstract: OBJECTIVE
  Fluoroquinolones and 3rd-generation cephalosporins that are prescribed for pneumonia may be avoided and replaced by a penicillin in some cases. We aimed to determine if the proportion of patients treated for pneumonia with a cephalosporin, a fluoroquinolone or both varies among Emergency Departments (EDs), and to estimate the proportion of avoidable prescriptions.
  
  
  METHODS
  This was a retrospective study of patients treated for pneumonia in eight French EDs, and subsequently hospitalized in non-ICU wards. Third-generation cephalosporins or respiratory fluoroquinolones were presumed unavoidable if they met both criteria: (1) age ≥65 years or comorbid condition; and (2) allergy or intolerance to penicillin, or failure of penicillin, or previous treatment with penicillin, or for fluoroquinolones only, suspected legionellosis.
  
  
  RESULTS
  We included 832 patients. Thirty-four percent (95 % CI, 31-38 %) of patients were treated with a cephalosporin, a respiratory fluoroquinolone or both (range among EDs 19-44 %). Four EDs were independent risk factors for prescription of a cephalosporin, a fluoroquinolone or both [adjusted OR, 2.27 (1.64-3.15)], as were immune compromise [aOR 2.54 (1.56-4.14)], antibacterial therapy started before arrival in the ED [aOR 3.32 (2.30-4.81)], REA-ICU class III or IV [aOR 1.93 (1.15-3.23)], PSI class V [aOR 1.49 (1.00-2.20)], fluid resuscitation [aOR 3.98 (2.49-6.43)] and non-invasive ventilation in the ED [aOR, 7.18 (1.7-50.1)]. Treatment with a cephalosporin, a fluoroquinolone or both was avoidable in 67 % (62-73 %) of patients.
  
  
  CONCLUSIONS
  Cephalosporins and fluoroquinolones use in pneumonia is highly variable among EDs. The majority of these prescriptions are avoidable. Antibiotic stewardship programs should be implemented to restrict their use in EDs.
authors.affiliation: Emergency Department, Centre Hospitalier Universitaire de Nantes, Hôtel-Dieu, 1 place Alexis-Ricordeau, 44000, Nantes, France. eric.batard@univ-nantes.fr.|Faculté de Médecine and Pharmacie, Université de Nantes, EA 3826 Thérapeutiques Cliniques et Expérimentales des Infections, 1 rue Gaston-Veil, 44000, Nantes, France. eric.batard@univ-nantes.fr.
authors.forename: Eric
authors.initials: E
authors.lastname: Batard
authors.affiliation: Emergency Department, Centre Hospitalier Universitaire de Nantes, Hôtel-Dieu, 1 place Alexis-Ricordeau, 44000, Nantes, France.
authors.forename: Nathalie
authors.initials: N
authors.lastname: Lecadet
authors.affiliation: Emergency Department, Centre Hospitalier Universitaire de Nantes, Hôtel-Dieu, 1 place Alexis-Ricordeau, 44000, Nantes, France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Goffinet
authors.affiliation: Faculté de Médecine and Pharmacie, Université de Nantes, EA 4275 SPHERE Biostatistics Pharmacoepidemiology and Human Science Research Team, 1 rue Gaston-Veil, 44000, Nantes, France.
authors.forename: Jean-Benoit
authors.initials: JB
authors.lastname: Hardouin
authors.affiliation: Faculté de Médecine and Pharmacie, Université de Nantes, EA 3826 Thérapeutiques Cliniques et Expérimentales des Infections, 1 rue Gaston-Veil, 44000, Nantes, France.|Department of Microbiology and Infection Control, Centre Hospitalier Universitaire de Nantes, Hôtel-Dieu, 1 place Alexis-Ricordeau, 44000, Nantes, France.
authors.forename: Didier
authors.initials: D
authors.lastname: Lepelletier
authors.affiliation: Emergency Department, Centre Hospitalier Universitaire de Nantes, Hôtel-Dieu, 1 place Alexis-Ricordeau, 44000, Nantes, France.|Faculté de Médecine and Pharmacie, Université de Nantes, EA 3826 Thérapeutiques Cliniques et Expérimentales des Infections, 1 rue Gaston-Veil, 44000, Nantes, France.
authors.forename: Gilles
authors.initials: G
authors.lastname: Potel
authors.affiliation: Emergency Department, Centre Hospitalier Universitaire de Nantes, Hôtel-Dieu, 1 place Alexis-Ricordeau, 44000, Nantes, France.|Faculté de Médecine and Pharmacie, Université de Nantes, EA 3826 Thérapeutiques Cliniques et Expérimentales des Infections, 1 rue Gaston-Veil, 44000, Nantes, France.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Montassier
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002511:Cephalosporins / Q000627:therapeutic use*; D017714:Community-Acquired Infections / Q000188:drug therapy*; D004363:Drug Utilization; D004636:Emergency Service, Hospital; D005260:Female; D024841:Fluoroquinolones / Q000627:therapeutic use*; D005602:France; D006801:Humans; D008297:Male; D010406:Penicillins / Q000627:therapeutic use; D018410:Pneumonia, Bacterial / Q000188:drug therapy*; D000091402:Prohibitins; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D002511:Cephalosporins; D024841:Fluoroquinolones; C000717331:PHB2 protein, human; D010406:Penicillins; D000091402:Prohibitins
keywords: Antibiotic prescription; Cephalosporins; Community-acquired pneumonia; Emergency department; Fluoroquinolones; Prudent use