A three-step critical pathway for community-acquired pneumonia reduces duration of hospital stay and intravenous antibiotic use by 2 days
- Correspondence to: Dr Paula Peyrani
Division of Infectious Diseases, University of Louisville, 501 E Broadway, MedCenter One, Suite 120, Louisville, KY 40202, USA;
Implications for practice and research
Although early switch therapy and hospital discharge are well-recognised processes, current practices show that these practices are not well established worldwide.
Pathways are useful tools to remind treating physicians about criteria for early switch and discharge.
A behavioural change may be necessary in order to decrease the gap between national recommendations and current management of hospitalised patients with community-acquired pneumonia.
Community-acquired pneumonia (CAP) remains within the 10 leading causes of death.1 Although the majority of patients with CAP are treated in the ambulatory setting, hospitalisations due to CAP remain as a transcendental decision not only from the perspective of patient management, but also from an economical standpoint. The cost of treatment of CAP as an inpatient is up to 25 times higher than that as an outpatient.1
Length of hospital stay (LOS) is the most important determinant of cost and is essentially determined by the duration of intravenous antibiotics. Although national guidelines established criteria for switch from intravenous to oral antibiotics (switch therapy) and hospital discharge, the local implementation of these processes may be challenging. In this study, Carratalà and colleagues evaluate a pathway to reduce duration of intravenous antibiotic therapy and LOS in hospitalised patients with CAP.
This was a prospective, randomised study performed at two tertiary hospitals in Barcelona, Spain, between 1 May 2005 and 31 December 2007. Immunocompetent hospitalised patients with CAP were invited to participate. Patients were randomly assigned to the interventional arm, a three-step pathway, or received usual care. To avoid biases, physicians were assigned to treat patients from one of these two groups only. As a reminder, a preprinted checklist was included in the chart of those patients randomised to the pathway arm. The three steps of the pathway were: (1) early mobilisation, (2) criteria for switch therapy and (3) criteria for hospital discharge. Primary endpoint was LOS. Sample size was calculated to be 380 patients to achieve 82% power at a 5% significance level, to detect a 1.5 day difference in LOS by t test.
From a total of 401 randomised patients included in an intention-to-treat analysis, 200 patients were assigned to the three-step pathway arm and 201 patients to the usual care arm. Regarding the study primary endpoint, median LOS for the three-step group was 3.9 days and for the usual care group was 6 days (difference −2.1 days, 95% CI −2.7 to −1.7, p<0.001). Median duration of intravenous antibiotic therapy for the three-step group was 2 days and for the usual care group was 4 days (difference −2 days, 95% CI −2.0 to −1.0, p<0.001).
Switch therapy and hospital discharge criteria were initially described almost 20 years ago as safe processes in hospitalised patients with CAP.2 ,3 However, the literature shows that this is not common practice.4 In this study, the authors identified that 94% of physicians who treated these patients were unaware of available guidelines for the timing of the switch from intravenous to oral antibiotics. Unpublished data from the CAPO study shows that in the USA and Canada early switch is performed in 63% of patients, in Europe in 43% and in Latin America in 38%. LOS is 9, 11 and 12 days, respectively.
Is a pathway the way to improve this gap between national recommendations and current practices? Pathways are a step in the right direction, but new interventions will be necessary to modify established practices and beliefs.