Community acquired pneumonia (CAP) is one of the leading causes of death in the United States. While most data regarding management of CAP comes from management of hospitalized patients, the majority of CAP cases are actually managed on an outpatient basis. The primary outcome of this study was to determine the incidence of appropriate diagnosis (based on Infectious Diseases Society of America (IDSA) guidelines) and appropriate treatment regimens, to identify potential stewardship targets in outpatients treated for CAP.
Patients were identified by ICD-9/10 codes for CAP. Patients were seen in the Veterans Affairs Western New York Healthcare System which consists of the emergency room, and local, home-based and rural clinics between January 2008 and January 2018. Those who were treated appropriately and those who were not were compared using Student’s t-test or Chi-square tests.
This study included 518 veterans with CAP. Sixty-six percent of veterans were deemed appropriate to treat. Of the 341 patients who had an appropriate diagnosis of CAP, 31% received an appropriate antibiotic regimen. Of those who were appropriate to treat, 76.7% received an incorrect drug based on comorbidities, 5.1% received an inappropriate dose, and 39.4% received an incorrect duration. Azithromycin was most commonly prescribed (45%) followed by a respiratory fluoroquinolone (38%) and doxycycline (10%). Patients with risk factors for drug resistant Streptococcus pneumoniae (DRSP) were more likely to be deemed appropriate to treat (81% vs 66%, p=0.002), however they were less likely to receive an appropriate antibiotic regimen (64% vs. 88%; p<0.0001). Being appropriate to treat was more likely with pneumococcal vaccinations PCV13 (35% vs 15%, p < 0.0001) and/or PPSV23 (72% vs 59%, p=0.003). A minority of patients re-presented within 30 days for CAP (4.1%) however, they were more likely to re-present if they had radiographic evidence of CAP on imaging (90.5%, p=0.03) and were considered appropriate to treat (91%, p=0.02).
Improvement in prescribing is needed in the outpatient setting for CAP. A stewardship program could target patients with risk factors for DRSP to improve compliance with the IDSA guidelines by ensuring appropriate antibiotic regimens.
J. Sellick, None
J. Schroeck, None
M. Skelly, None
R. Napierala, None