Department of Pharmacy, Veteran Affairs Western New York Healthcare System, Buffalo, NY, USA.
Medical Service, Veteran Affairs Western New York Healthcare System, Buffalo, NY, USA; Division of Infectious Diseases, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA.
Clin Ther. 2019 Mar;41(3):466-476. doi: 10.1016/j.clinthera.2019.01.007. Epub 2019 Feb 8.
Community-acquired pneumonia (CAP) is one of the leading causes of death in the United States. The primary objective of this study was to determine the prevalence of appropriate diagnosis and treatment of outpatients treated for CAP. Knowledge of problems with CAP treatment can be helpful in developing stewardship initiatives to improve care of outpatients with CAP.
Included in this study were patients 18 years and older who received antibiotic therapy for the treatment of CAP in the outpatient setting. Outpatients were identified by International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, Tenth Revision (ICD-10) codes for CAP in the Veterans Affairs Western New York Healthcare System between January 2008 and January 2018. Appropriate treatment was evaluated using CAP guidelines. Factors associated with an inappropriate regimen were determined via multivariable analyses.
This study included 518 outpatients, of whom 66% were appropriately diagnosed with CAP. Of the 341 appropriately diagnosed patients, only 31% received an antibiotic regimen consistent with guidelines. Regarding inappropriate regimens, 76.7% contained an incorrect drug based on patient comorbidities, and 39.4% consisted of an inappropriate duration, which was most often attributable to prolonged length of therapy >7 days. The odds of being prescribed an inappropriate regimen if a patient was considered to be at risk for drug-resistant Streptococcus pneumoniae (DRSP) was 4.2 (95% CI, 2.4-7.4). The population at risk for DRSP was more likely to present to the health care system again within 30 days compared with low-risk patients (19.4% vs 8.7%, P = 0.005).
Improvement in prescribing is needed for CAP. An outpatient stewardship program that targets patients with risk factors for DRSP would improve adherence to guidelines.
社区获得性肺炎（CAP）是美国主要的死亡原因之一。本研究的主要目的是确定门诊治疗 CAP 的患者中适当诊断和治疗的流行情况。了解 CAP 治疗中存在的问题有助于制定管理策略，以改善门诊 CAP 患者的护理。
本研究纳入了在退伍军人事务部西纽约医疗保健系统中，18 岁及以上因 CAP 在门诊接受抗生素治疗的患者。在 2008 年 1 月至 2018 年 1 月期间，通过国际疾病分类第 9 版（ICD-9）和国际疾病分类第 10 版（ICD-10）代码确定 CAP 门诊患者。使用 CAP 指南评估适当的治疗方法。通过多变量分析确定与不适当方案相关的因素。
本研究纳入了 518 名门诊患者，其中 66%的患者被适当诊断为 CAP。在 341 名被适当诊断的患者中，只有 31%的患者接受了符合指南的抗生素方案。关于不适当的方案，76.7%的方案中含有根据患者合并症选择的不正确药物，39.4%的方案中包含了不适当的疗程，这主要归因于治疗时间过长（>7 天）。如果患者被认为有耐药肺炎链球菌（DRSP）风险，则处方不适当方案的可能性为 4.2（95%置信区间，2.4-7.4）。有 DRSP 风险的患者在 30 天内再次到医疗系统就诊的可能性高于低风险患者（19.4%比 8.7%，P=0.005）。
需要改进 CAP 的处方。针对具有 DRSP 风险因素的患者的门诊管理计划将提高对指南的遵循率。
