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Research Reveals Opportunities for Antimicrobial Stewardship When Treating Community-Acquired Pneumonia
Results suggest that patients commonly receive more than 5 days of treatment, which could be an opportunity for an antimicrobial stewardship initiative.
Research findings presented in a poster session at the American Society of Health-System Pharmacists (ASHP) 2024 Midyear Clinical Meeting suggest that community acquired pneumonia (CAP) is often treated with antibiotics for longer than the recommended duration, offering new opportunities for pharmacist-led antimicrobial stewardship.1
Illustration of lungs with pneumonia bacteria | Image credit: Dr_Microbe | stock.adobe.com
CAP is a leading cause of morbidity and mortality. Clinical presentation can include fever and productive cough, or respiratory distress and sepsis in severe cases. It accounts for more than 4.5 million outpatient and emergency department visits annually and is the second most common cause of hospitalization and the most common infectious cause of death.2
Risk factors for CAP include older age, chronic comorbidities, viral respiratory tract infection, smoking, and other lifestyle factors such as crowded living conditions or low-income settings. Streptococcus pneumoniae and respiratory viruses are the most frequently detected pathogens in patients with CAP.2
In addition to support of oxygenation and other vital functions, the major goal of therapy is eradication of the infecting organism. There are various antibiotic regimens available, with little evidence supporting one over the others. For individuals with no risk factors for methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa, options include amoxicillin, doxycycline, macrolide (if local pneumococcal resistance), and clarithromycin. Different dosing strategies are available for individuals with various comorbidities.3
“As we know, the [Infectious Diseases Society of America] guidelines recommend a minimum of 5 days of treatment for CAP, but about 70% of patients nationwide are actually being over-treated longer than those 5 days,” said Alyssa Chuidian, a PharmD candidate at Texas Southern University College of Pharmacy in Houston, in an interview with Pharmacy Times. “So at my institution specifically, we wanted to look at where we are, if we are in line with the guidelines or if we are giving longer durations of therapy.”
The research presented at ASHP utilized retrospective data to assess the duration of antibiotic therapy among 1401 patients hospitalized at Houston Methodist Hospital for CAP between January 2023 and December 2023. To be included, patients had to be 18 years of age or older; admitted with CAP and suspected respiratory infections; and receiving antibiotics with an indication for sepsis or respiratory treatments.1
The primary end point was the length of therapy (LOT) for treatment of CAP, defined as inpatient LOT plus outpatient LOT. Secondary end points included length of hospital stay, incidence of readmission at 30 days, and incidence of readmission at 90 days.1
According to the findings, the mean total LOT was 8.07 days, consisting of a mean of 5.62 days inpatient and 2.45 days outpatient. In total, 68.8% of the participants received more than 5 days of treatment, and 48.9% received 8 or more days of therapy—well above the recommended 5 days.1 The incidence of readmission rates were similar between patients with shorter and longer length of therapies, and patients with a shorter length of hospital stay were more likely to receive an outpatient prescription than patients with a longer length of stay.1
“I wanted to assess if patients with longer than 7 days of treatment versus less than 7 days of treatment were more likely to be readmitted at 30 and 90 days,” Chuidian said. “And I actually found that it was similar between the 2 groups, at about 10% for less than 7 days and about 11% for more than 7 days, so it kind of shows you that regardless of if they received more than 7 days or less than 7 days, they weren’t any different in readmission rates.”
These results suggest that patients commonly receive more than 5 days of treatment, which could be an opportunity for an antimicrobial stewardship initiative to prescribe shorter durations of treatment. The study was limited by the absence of antibiotic selection, the use of outpatient fill records for outpatient duration of therapy, and lack of assessment of the specific causative pathogen for CAP.1
“Over-treatment is a big issue, so 50% of our patients were still receiving more than 8 days,”
Chuidian said. “So there’s room for antimicrobial stewardship initiatives and for getting the physicians involved [so they] know that they’re over-treating.”
REFERENCES
1. Chuidian A, Tsai S, Finch N, Hoffmann W. Assessing the duration of therapy to treat community-acquired pneumonia (CAP) at a large academic hospital. Presented at: American Society of Health-System Pharmacists 2024 Midyear Clinical Meeting. New Orleans, LA. December 10, 2024.
2. Overview of community-acquired pneumonia in adults. UpToDate. Updated November 12, 2024. Accessed December 10, 2024. https://www.uptodate.com/contents/overview-of-community-acquired-pneumonia-in-adults
3. Community-acquired pneumonia: updated recommendations from the ATS and IDSA. Am Fam Physician. 2020;102(2):121-124.
