Colmerauer Jessica L, Linder Kristin E, Dempsey Casey J, Kuti Joseph L, Nicolau David P, Bilinskaya Anastasia
Hartford Hospital, Hartford, CT, USA.
Hosp Pharm. 2022 Aug;57(4):496-503. doi: 10.1177/00185787211055797. Epub 2021 Nov 8.
Following updates to the Infectious Diseases Society of America (IDSA) practice guidelines for the Diagnosis and Treatment of Adults with Community-acquired Pneumonia in 2019, Hartford HealthCare implemented changes to the community acquired pneumonia (CAP) order-set in August 2020 to reflect criteria for the prescribing of broad-spectrum antimicrobial therapy. The objective of the study was to evaluate changes in broad-spectrum antibiotic days of therapy (DOT) following these order-set updates with accompanying provider education. This was a multi-center, quasi-experimental, retrospective study of patients with a diagnosis of CAP from September 1, 2019 to October 31, 2019 (pre-intervention) and September 1, 2020 to October 31, 2020 (post-intervention). Patients were identified using ICD-10 codes (A48.1, J10.00-J18.9) indicating lower respiratory tract infection. Data collected included demographics, labs and vitals, radiographic, microbiological, and antibiotic data. The primary outcome was change in broad-spectrum antibiotic DOT, specifically anti-pseudomonal β-lactams and anti-MRSA antibiotics. Secondary outcomes included guideline-concordance of initial antibiotics, utilization of an order-set to prescribe antibiotics, and length of stay (LOS). A total of 331 and 352 patients were included in the pre- and post-intervention cohorts, respectively. There were no differences in order-set usage (10% vs 11.3%, = .642) between the pre- and post-intervention cohort, respectively. The overall duration of broad-spectrum therapy was a median of 2 days (IQR 0-8 days) in the pre-intervention period and 0 days (IQR 0-4 days) in the post-intervention period ( < .001). Patients in whom the order-set was used in the post-intervention period were more likely to have guideline-concordant regimens ([36/40] 90% vs [190/312] 60.9%; = .003). Hospital LOS was shorter in the post-intervention cohort (4.8 days [2.9-7.2 days] vs 5.3 days [IQR 3.5-8.5 days], = .002). Implementation of an updated CAP order-set with accompanying provider education was associated with reduced use of broad-spectrum antibiotics. Opportunities to improve compliance and thus further increase guideline-concordant therapy require investigation.
在美国传染病学会（IDSA）于2019年对成人社区获得性肺炎的诊断和治疗实践指南进行更新之后，哈特福德医疗保健公司于2020年8月对社区获得性肺炎（CAP）医嘱集进行了修改，以反映广谱抗菌治疗的处方标准。本研究的目的是评估在这些医嘱集更新并伴有医务人员培训之后，广谱抗生素治疗天数（DOT）的变化。这是一项多中心、准实验性、回顾性研究，研究对象为2019年9月1日至2019年10月31日（干预前）以及2020年9月1日至2020年10月31日（干预后）被诊断为CAP的患者。使用国际疾病分类第十版（ICD - 10）编码（A48.1，J10.00 - J18.9）来识别表明下呼吸道感染的患者。收集的数据包括人口统计学信息、实验室检查和生命体征、影像学、微生物学以及抗生素数据。主要结局是广谱抗生素DOT的变化，具体为抗假单胞菌β - 内酰胺类和抗耐甲氧西林金黄色葡萄球菌（MRSA）抗生素。次要结局包括初始抗生素的指南依从性、使用医嘱集来开具抗生素的情况以及住院时间（LOS）。干预前和干预后队列分别纳入了331例和352例患者。干预前和干预后队列之间在医嘱集使用方面无差异（分别为10%对11.3%，P = 0.642）。干预前期广谱治疗的总时长中位数为2天（四分位间距0 - 8天），干预后期为0天（四分位间距0 - 4天）（P < 0.001）。在干预后期使用医嘱集的患者更有可能采用符合指南的治疗方案（[36/40] 90%对[190/312] 60.9%；P = 0.003）。干预后队列的住院时间更短（4.8天[2.9 - 7.2天]对5.3天[四分位间距3.5 - 8.5天]，P = 0.002）。实施更新后的CAP医嘱集并伴有医务人员培训与广谱抗生素使用减少相关。改善依从性从而进一步增加指南依从性治疗的机会有待研究。
