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Length of antibiotic therapy among adults hospitalized with uncomplicated community-acquired pneumonia, 2013–2020
- Natalie L. McCarthy, James Baggs, Hannah Wolford, Sophia V. Kazakova, Sarah Kabbani, Brandon K. Attell, Melinda M. Neuhauser, Lindsey Walker, Sarah H. Yi, Kelly M. Hatfield, Sujan Reddy, Lauri A. Hicks
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 45 / Issue 6 / June 2024
- Published online by Cambridge University Press:
- 14 February 2024, pp. 726-732
- Print publication:
- June 2024
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Objective:
The 2014 US National Strategy for Combating Antibiotic-Resistant Bacteria (CARB) aimed to reduce inappropriate inpatient antibiotic use by 20% for monitored conditions, such as community-acquired pneumonia (CAP), by 2020. We evaluated annual trends in length of therapy (LOT) in adults hospitalized with uncomplicated CAP from 2013 through 2020.
Methods:We conducted a retrospective cohort study among adults with a primary diagnosis of bacterial or unspecified pneumonia using International Classification of Diseases Ninth and Tenth Revision codes in MarketScan and the Centers for Medicare & Medicaid Services databases. We included patients with length of stay (LOS) of 2–10 days, discharged home with self-care, and not rehospitalized in the 3 days following discharge. We estimated inpatient LOT based on LOS from the PINC AI Healthcare Database. The total LOT was calculated by summing estimated inpatient LOT and actual postdischarge LOT. We examined trends from 2013 to 2020 in patients with total LOT >7 days, which was considered an indicator of likely excessive LOT.
Results:There were 44,976 and 400,928 uncomplicated CAP hospitalizations among patients aged 18–64 years and ≥65 years, respectively. From 2013 to 2020, the proportion of patients with total LOT >7 days decreased by 25% (68% to 51%) among patients aged 18–64 years and by 27% (68%–50%) among patients aged ≥65 years.
Conclusions:Although likely excessive LOT for uncomplicated CAP patients decreased since 2013, the proportion of patients treated with LOT >7 days still exceeded 50% in 2020. Antibiotic stewardship programs should continue to pursue interventions to reduce likely excessive LOT for common infections.
Empiric antibiotic selection for community-acquired pneumonia in US hospitals, 2013–2020
- Hannah Wolford, Brandon Attell, James Baggs, Sujan Reddy, Sarah Kabbani, Melinda Neuhauser, Lauri Hicks
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- Journal:
- Antimicrobial Stewardship & Healthcare Epidemiology / Volume 3 / Issue S2 / June 2023
- Published online by Cambridge University Press:
- 29 September 2023, pp. s26-s27
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Background: Community-acquired pneumonia (CAP) is a common indication for antibiotic prescribing in hospitalized patients. Professional societies’ clinical guidelines recommend specific antibiotics for empiric treatment of CAP based on clinical factors. Manual assessments of appropriateness are time-consuming and are often conducted on a smaller scale. We evaluated empiric antibiotic selection among a large cohort of adults hospitalized with CAP using electronic health records. Methods: In this study, we used the PINC-AI healthcare database to define a cohort of adults hospitalized with CAP from 2013 to 2020. CAP was identified by International Classification of Diseases (ICD) diagnosis codes. Exclusions were applied to identify uncomplicated CAP (Fig. 1). Treatment was only evaluated if a chest radiograph or computerized tomography (CT) scan was charged during the first 2 days of hospitalization, otherwise it was considered an inadequate CAP evaluation. Administrative billing data were used to identify antibiotics charged within the first 2 days of hospitalization. Empiric guideline-recommended treatment was determined based on 2019 CAP guidelines and more recent studies. Patients who received nonrecommended treatment were evaluated for antibiotic allergies in the current hospitalization or methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection in the year prior or on admission using International Classification of Disease, Tenth Revision (ICD-10) diagnosis codes. Results: We identified 4.47 million adult hospitalizations with CAP from 2013 to 2020; 32% (1.43 million) were included in this analysis (Fig. 1). Among discharges with adequate CAP evaluation (1.37 million), 59.7% received recommended antibiotics in the first 2 days of hospitalization, ranging from 62.6% in 2013 to 57.5% in 2019. Overall, 34.8% of our study population received a nonrecommended antibiotic without documentation of an antibiotic allergy or MRSA colonization (2013: 32.5%; 2018: 36.7%) (Fig. 2). Most patients in our study population received >1 antibiotic (92.3%) in the first 2 days of hospitalization. The most common antibiotics among patients receiving recommended treatment were ceftriaxone (74.2% of patients receiving recommended treatment), azithromycin (67.2%), and levofloxacin (31.8%) (Fig. 3a). The most common nonrecommended antibiotics were vancomycin (57.2% of patients receiving nonrecommended treatment), piperacillin-tazobactam (48.1%), and cefepime (25.7%) (Fig. 3b). From 2013 to 2020, cefepime charges consistently increased among CAP patients treated with nonrecommended antibiotics, whereas levofloxacin charges consistently decreased among CAP patients treated with only recommended antibiotics. Conclusions: Approximately one-third of patients with uncomplicated CAP received nonrecommended empiric antibiotics, and from 2013 to 2020 that proportion increased by 9%. Additional strategies are needed to help identify opportunities to optimize antibiotic selection among patients with CAP.
Disclosures: None
Length of antibiotic therapy among adults aged ≥65 years hospitalized with uncomplicated community-acquired pneumonia, 2013-2020
- Natalie McCarthy, Hannah Wolford, Sophia Kazakova, James Baggs, Brandon Attell, Sarah Kabbani, Melinda Neuhauser, Sarah Yi, Kelly Hatfield, Sujan Reddy, Lauri Hicks
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- Journal:
- Antimicrobial Stewardship & Healthcare Epidemiology / Volume 3 / Issue S2 / June 2023
- Published online by Cambridge University Press:
- 29 September 2023, p. s26
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- Article
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- You have access Access
- Open access
- Export citation
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Background: The 2014 US National Strategy for Combating Antibiotic-Resistant Bacteria aimed to reduce inappropriate inpatient antibiotic use by 20% for monitored conditions, such as community-acquired pneumonia (CAP), by 2020. Clinical guidelines recommend treating uncomplicated CAP with a minimum of 5 days of antibiotic therapy. Total length of therapy (LOT) >7 days or >3 days after clinical improvement is rarely necessary. In a previous study estimating LOT in uncomplicated CAP patients, 71% of patients ≥65 years exceeded recommended duration of antibiotics in 2012–2013 (Yi et al, 2018). We evaluated annual trends in LOT in adults ≥65 years hospitalized with uncomplicated CAP from 2013 to 2020. Methods: We conducted a retrospective cohort study among patients in the CMS database with a primary diagnosis of bacterial or unspecified pneumonia using International Classification of Diseases 9th and 10th Revision codes, length of stay (LOS) of 2–10 days, discharged home with self-care, and not rehospitalized in the 3 days following discharge. Discharge home was used as a surrogate for clinical improvement. Because inpatient LOT is not available in CMS data, we used linear regression to model inpatient LOT as a function of LOS using data on CAP patients ≥65 years from the PINC AI healthcare database. Postdischarge LOT was based on prescriptions filled following discharge. Total LOT was calculated by summing estimated inpatient LOT and actual postdischarge LOT (Fig. 1). Total LOT >7 days and postdischarge LOT >3 days were considered indicators of likely excessive LOT. We reported trends in the proportion of patients with likely excessive LOT during the study period. Results: From 2013 through 2020, there were 400,928 uncomplicated CAP hospitalizations among patients aged ≥65 years. Patients were more likely to be female (55%), and they had a median age of 76 years and a median LOS of 3 days. The median total LOT decreased from 9.5 days in 2013 to 7.7 days in 2020. The proportion of patients with total LOT >7 days decreased from 68% in 2013 to 50% in 2020 (% change, −27%); the proportion with postdischarge LOT >3 days decreased from 73% in 2013 to 62% in 2020 (% change, −16%) (Fig. 2). Conclusions: Likely excessive total LOT for adults ≥65 years hospitalized with uncomplicated CAP decreased by 27% in 2020, a considerable improvement from 2013. However, the high proportion of patients with likely excessive postdischarge LOT in 2020 (62%) demonstrates the need for antibiotic stewardship to optimize prescribing at hospital discharge.
Disclosures: None