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Can CAP guideline adherence improve patient outcome in internal medicine departments?

¹ Institute of Respiratory Diseases, University of Milan, Maggiore Hospital, Fondazione IRCCS Policlinico, Mangiagalli e Regina Elena, ⁶ Institute of Respiratory Diseases, University of Milan, "L. Sacco" Hospital, Milan, ² Dept of Internal Medicine, Azienda Ospedaliera Arcispedale Santa Maria Nuova, Centro Studi FADOI, Reggio Emilia, ³ Internal Medicine Unit, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia di Udine, Centro Studi FADOI, Udine, ⁴ Biomedical Dept of Internal Medicine, University of Palermo, Centro studi FADOI, Palermo, and ⁵ Dept of Internal Medicine, University Campus Bio-Medico, Centro studi FADOI, Rome, Italy.

CORRESPONDENCE: F. Blasi, Istituto Malattie dell’Apparato Respiratorio, University of Milan, Padiglione Sacco Ospedale Maggiore Fondazione IRCCS Policlinico, Mangiagalli e Regina Elena, Via F. Sforza 35, 20122 Milan, Italy. Fax: 39 0250320628. E-mail: francesco.blasi{at}unimi.it

Keywords: Antibiotic, community-acquired pneumonia, guidelines

Received: July 22, 2007
Accepted May 8, 2008

The impact of compliance with Italian guidelines on the outcome of hospitalised community-acquired pneumonia (CAP) in internal medicine departments was evaluated.

All Fine class IV or V CAP patients were included in this multicentre, interventional, before-and-after study, composed of three phases: 1) a retrospective phase (RP; 1,443 patients); 2) a guideline implementation phase; and 3) a prospective phase (PP; 1,404 patients).

Antibiotic prescription according to the guidelines increased significantly in the PP. The risk of failure at the end of the firstline therapy was significantly lower in the PP versus the RP (odds ratio (OR) 0.83, 95% confidence interval (CI) 0.69–1.00), particularly in Fine class V patients (OR 0.71, 95% CI 0.51–0.98). Analysis of outcome in the overall population (2,847 patients) showed a statistically significant advantage for compliant versus noncompliant therapies in terms of failure rate (OR 0.74, 95% CI 0.60–0.90) and an advantage in terms of mortality (OR 0.77, 95% CI 0.58–1.04). Antipneumococcal cephalosporin monotherapy was associated with a low success rate (68.6%) and the highest mortality (16.2%); levofloxacin alone and the combination of cephalosporin and macrolide resulted in higher success rates (79.1 and 76.7%, respectively) and significantly lower mortalities (9.1 and 5.7%, respectively).

Overall, a low compliance with guidelines in the prospective phase (44%) was obtained, indicating the need for future more aggressive and proactive approaches.