Program Schedule

1792
Higher Adherence to an Inpatient Treatment Guideline for Community-acquired Pneumonia is Associated with Reduced Mortality in Botswana

Session: Oral Abstract Session: Global Infectious Diseases
Saturday, October 11, 2014: 3:00 PM
Room: The Pennsylvania Convention Center: 111-AB
Background:

Botswana has an HIV prevalence of 19% among those aged 18 months-64 years. Community-acquired pneumonia (CAP) is a leading cause for admission to our referral hospital in Gaborone.  We collaborated with the Ministry of Health and the University of Botswana to implement an inpatient treatment guideline for CAP.  We hypothesized that implementation of a guideline for CAP would be associated with improved clinical outcomes.

Methods:

We performed a prospective observational study among adults admitted with CAP to evaluate guideline use.  Inclusion criteria:  age >18, diagnosis of CAP and meeting the case definition of CAP. Data collection captured HIV status, CD4 count, antimicrobials used, chest radiograph findings, microbiologic diagnoses and outcomes. We assessed mortality by contacting study subjects or a designated contact at 30 days following discharge.  Guideline fidelity was assessed by a 5 point score assigning 1 point for each of the following:  appropriate antibiotic use (1 point for Beta-lactam, 1 point for doxycycline or erythromycin), blood cultures obtained, smear for acid fast bacilli obtained on HIV-infected patients or subjects with cough > one week, chest radiograph reviewed.  Analysis compared proportions using Chi-square test at the 95% confidence level, and rank sum test for continuous measures. 

Results:

Patient demographics are included in the table below: 

Characteristic

HIV-

HIV+

Total

p value

n

% or median & IQR

n

% or median & IQR

n

% or median & IQR

Total

74

17%

365

83%

441

100%

 

Age

74

61 (40-67)

365

38 (32-45)

441

39 (32-49)

<0.0001

Diabetes

12/74

16%

9/364

2%

21/440

5%

0.0001

Chronic renal failure

4/74

5%

9/365

2%

13/441

3%

0.17

Chronic heart disease

9/74

12%

2/365

0.5%

11/441

2%

0.0001

COPD

8/74

11%

5/364

1%

13/440

3%

0.0001

Underlying malignancy

1/74

1%

1/365

0.3%

2/440

0.5%

0.22

Antibiotics in past 3 months

2/73

3%

11/364

3%

13/439

3%

0.90

Overall 30-day mortality was 24%.  Mortality among HIV-infected subjects was 24% and among HIV-negative subjects was 23%, p=0.8.  Mean guideline adherence score for those who were alive at 30 days was 2.45 (95% CI 2.34-2.56) compared to those who died, 2.09 (95% CI 1.87-2.32), p=0.006.

Conclusion:

In this setting, higher adherence to a guideline for community-acquired pneumonia is associated with a reduction in mortality.

Michelle Haas, MD1,2,3,4, Raina Phillips, MD3,4, Harvey Friedman, MD3,4, Bakgaki Ratshaa4 and Ari Ho-Foster, MSc3,4, (1)Medicine/Infectious Diseases, Denver Health Medical Center, Denver, CO, (2)Medicine/Infectious Diseases, University of Colorado-Denver Health Sciences Center, Denver, CO, (3)Medicine/Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, (4)Botswana-UPenn Partnership, Gaborone, Botswana

Disclosures:

M. Haas, None

R. Phillips, None

H. Friedman, None

B. Ratshaa, None

A. Ho-Foster, None

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