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210
LETTERS TO THE EDITOR
Emergency department guideline concordance with respect to pneumonia antibiotic therapy: We can do better Dear Editor, In the treatment of community-acquired pneumonia (CAP), the Australian therapeutic guidelines recommend use of pneumonia severity scoring tools, which in turn guides prescription of appropriate antibiotic therapy.1 These recommended tools currently include the SMART-COP and CORB scoring systems.1 These tools are useful for both prognostic purposes and in guiding treatment. Increased bacterial resistance results from inappropriate use of antibiotics and can lead to adverse effects on public health outcomes.2 CAP is responsible for a large proportion of antibiotic consumption in hospitals,3 and treatment of this condition is usually initiated in the ED. Previous Australian studies on this topic have found low levels of guideline concordance4 but have not served to raise awareness among emergency physicians by publishing in emergency medicine journals. Furthermore, previous studies have tended to focus on the Pneumonia Severity Index rather than the currently recommended SMART-COP and CORB severity scoring systems. Therefore, a retrospective audit was performed in an Australian rural base hospital ED over a 3-month winter period to investigate guideline concordance with respect to management of CAP. Specifically, to determine the percentage of adult CAP presentations that were: (i) assessed using one of the guideline-recommended pneumonia severity scoring tools; and (ii) prescribed guideline-concordant antibiotic therapy. De-identified retrospective audit data were obtained on all adult CAP presentations that met the inclusion
criteria over the three consecutive winter months of 2011. Severity scores were calculated for each presentation using the guideline-recommended pneumonia severity scoring tools (CORB and SMART-COP). Categorical data were compared using Fisher’s exact test.5 Of the 54 included patients, there was no documented use of guidelinerecommended pneumonia severity scoring tools and the level of concordance with prescribing guidelines was low (Table 1). There was no correlation between severity of CAP and concordance with guidelines. Ceftriaxone was prescribed to 59.3% of patients, without evidence of correlation to CAP severity. There was a statistically significant positive correlation between ICU admission and calculated CAP severity (P < 0.05). Admittedly, blind adherence to guidelines might result in an oversimplified approach to complex clinical situations and clinical judgment should remain paramount. However, the findings of very poor levels of guideline concordance is concerning. An increased awareness among ED clinicians of the existence and utility of the
TABLE 1. Main outcome results Percentage use of pneumonia severity scoring tools
Percentage of cases treated with guidelineconcordant antibiotic therapy
0% 5.6% (95% CI 0–8.3) (95% CI 1.5–16.4)
currently recommended pneumonia severity scoring tools would likely improve guideline concordance, as well as individual patient and public health outcomes.
Competing interests None declared.
References 1. Antibiotic Expert Group. Therapeutic Guidelines: Antibiotic, Version 14. Melbourne: Therapeutic Guidelines Limited, 2010. 2. Davey P, Brown E, Fenelon L et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst. Rev. 2005; CD003543. 3. Buising KL, Thursky KA, Black JF et al. Empiric antibiotic prescribing for patients with community-acquired pneumonia: where can we improve? Intern. Med. J. 2008; 38: 174–7. 4. McIntosh K, Maxwell D, Pulver LK et al. A quality improvement initiative to improve adherence to national guidelines for empiric management of community-acquired pneumonia in emergency departments. Int. J. Qual. Health Care 2010; 23: 142–50. 5. Fisher RA, Bennett JH, Yates F. Statistical Methods, Experimental Design, and Scientific Inference: A ReIssue of Statistical Methods for Research Workers, The Design of Experiments, and Statistical Methods and Scientific Interference. Oxford: Oxford University Press, 1990.
Stephen J NAUGHTIN The Tweed Hospital, Tweed Heads, New South Wales, Australia doi: 10.1111/1742-6723.12197
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
210
LETTERS TO THE EDITOR
Emergency department guideline concordance with respect to pneumonia antibiotic therapy: We can do better Dear Editor, In the treatment of community-acquired pneumonia (CAP), the Australian therapeutic guidelines recommend use of pneumonia severity scoring tools, which in turn guides prescription of appropriate antibiotic therapy.1 These recommended tools currently include the SMART-COP and CORB scoring systems.1 These tools are useful for both prognostic purposes and in guiding treatment. Increased bacterial resistance results from inappropriate use of antibiotics and can lead to adverse effects on public health outcomes.2 CAP is responsible for a large proportion of antibiotic consumption in hospitals,3 and treatment of this condition is usually initiated in the ED. Previous Australian studies on this topic have found low levels of guideline concordance4 but have not served to raise awareness among emergency physicians by publishing in emergency medicine journals. Furthermore, previous studies have tended to focus on the Pneumonia Severity Index rather than the currently recommended SMART-COP and CORB severity scoring systems. Therefore, a retrospective audit was performed in an Australian rural base hospital ED over a 3-month winter period to investigate guideline concordance with respect to management of CAP. Specifically, to determine the percentage of adult CAP presentations that were: (i) assessed using one of the guideline-recommended pneumonia severity scoring tools; and (ii) prescribed guideline-concordant antibiotic therapy. De-identified retrospective audit data were obtained on all adult CAP presentations that met the inclusion
criteria over the three consecutive winter months of 2011. Severity scores were calculated for each presentation using the guideline-recommended pneumonia severity scoring tools (CORB and SMART-COP). Categorical data were compared using Fisher’s exact test.5 Of the 54 included patients, there was no documented use of guidelinerecommended pneumonia severity scoring tools and the level of concordance with prescribing guidelines was low (Table 1). There was no correlation between severity of CAP and concordance with guidelines. Ceftriaxone was prescribed to 59.3% of patients, without evidence of correlation to CAP severity. There was a statistically significant positive correlation between ICU admission and calculated CAP severity (P < 0.05). Admittedly, blind adherence to guidelines might result in an oversimplified approach to complex clinical situations and clinical judgment should remain paramount. However, the findings of very poor levels of guideline concordance is concerning. An increased awareness among ED clinicians of the existence and utility of the
TABLE 1. Main outcome results Percentage use of pneumonia severity scoring tools
Percentage of cases treated with guidelineconcordant antibiotic therapy
0% 5.6% (95% CI 0–8.3) (95% CI 1.5–16.4)
currently recommended pneumonia severity scoring tools would likely improve guideline concordance, as well as individual patient and public health outcomes.
Competing interests None declared.
References 1. Antibiotic Expert Group. Therapeutic Guidelines: Antibiotic, Version 14. Melbourne: Therapeutic Guidelines Limited, 2010. 2. Davey P, Brown E, Fenelon L et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst. Rev. 2005; CD003543. 3. Buising KL, Thursky KA, Black JF et al. Empiric antibiotic prescribing for patients with community-acquired pneumonia: where can we improve? Intern. Med. J. 2008; 38: 174–7. 4. McIntosh K, Maxwell D, Pulver LK et al. A quality improvement initiative to improve adherence to national guidelines for empiric management of community-acquired pneumonia in emergency departments. Int. J. Qual. Health Care 2010; 23: 142–50. 5. Fisher RA, Bennett JH, Yates F. Statistical Methods, Experimental Design, and Scientific Inference: A ReIssue of Statistical Methods for Research Workers, The Design of Experiments, and Statistical Methods and Scientific Interference. Oxford: Oxford University Press, 1990.
Stephen J NAUGHTIN The Tweed Hospital, Tweed Heads, New South Wales, Australia doi: 10.1111/1742-6723.12197
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
