Update in Pulmonary Medicine

Pneumonia

Nonadherence to Guidelines Was an Independent Risk Factor for Treatment Failure and Death

Several guidelines help physicians to manage patients with community-acquired pneumonia, but as with most guidelines, adherence varies. Menéndez and colleagues sought to identify factors that influenced adherence to guideline recommendations for selecting empirical antibiotics for community-acquired pneumonia and to evaluate the effect of adherence on treatment failure and death.

The investigators prospectively gathered data on 1228 patients with community-acquired pneumonia and their providers at 15 hospitals in Spain. They collected data on each patient's age, sex, previous antibiotic treatment, comorbid conditions, and pneumonia severity index scores and on the provider's specialty and level of experience or training. Adherence was based on the latest consensus Spanish guidelines (1) and was defined as provision of a third-generation cephalosporin (cefotaxime or ceftriaxone), amoxicillin–clavulanate with or without a macrolide, or a third- or fourth-generation fluoroquinolone to non–intensive care unit patients and provision of a third- or fourth-generation cephalosporin combined with an intravenous macrolide or an intravenous fluoroquinolone to intensive care unit patients. Primary end points were treatment failure requiring increased therapy or intensive care unit admission (if patients were initially admitted to the ward), chest tube drainage for a parapneumonic effusion, and death.

Initial empirical therapy was adherent to that recommended in the guidelines in 979 patients (79.7%). In a multivariate analysis based on 1134 of the 1228 patients, statistically significant risk factors for nonadherence were admission to an intensive care unit (odds ratio, 0.43 [95% CI, 0.24 to 0.78]) and hospitalization at several of the 13 hospitals, while risk factors for …