Can CAP Guideline Adherence Improve Patient Outcome in Internal Medicine Departments?

¹ Istituto di Tisiologia e Malattie dell'Apparato Respiratorio, University of Milan, Ospedale Maggiore Fondazione IRCCS Policlinico, Mangiagalli e Regina Elena Milan, Italy. E-mail: Francesco.blasi@unimi.it
² Dept of Internal Medicine Azienda Ospedaliera Arcispedale S. Maria Nuova, Reggio Emilia Italy, Centro studi FADOI. E-mail: ido.iori@asmn.re.it
³ Internal Medicine Unit, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia di Udine, FADOI, Italy. E-mail: bulfoni.alessandro@aoud.sanita.fvg.it
⁴ Biomedical Dept of Internal Medicine, University of Palermo, Italy, Centro studi FADOI. E-mail: s.corrao@tiscali.it
⁵ Internal Medicine Dept, University Campus Bio-Medico, Rome, FADOI, Italy. E-mail: s.costantino@unicampus.it
⁶ Istituto di Tisiologia e Malattie dell'Apparato Respiratorio, University of Milan, Ospedale "L. Sacco" Milan, Italy. E-mail: delfino.legnani@unimi.it

^* To whom correspondence should be addressed. E-mail: francesco.blasi{at}unimi.it.

	Abstract

We evaluated the impact of compliance with Italian Guidelines on the outcome of hospitalised community-acquired pneumonia (CAP) in Internal Medicine departments. All Fine class IV or V CAP patients were included in this multicentre, interventional, before-after study composed of three phases: 1) a retrospective phase (RP) (1443 patients); 2) Guideline implementation; 3) a prospective phase (PP) (1404 patients).

Antibiotic prescribing according to guidelines significantly increased in the PP (p<0.01).

The risk of failure at the end of the first line of therapy was significantly lower in the PP versus the RP (p=0.049; OR, 95%CI: 0.83, 0.69–1.00), particularly in Fine class V patients (p=0.036;OR,95%CI:0.71,0.51–0.98).

Analysis of outcome in the overall population (2847 patients) showed a statistically significant advantage for compliant vs. non-compliant therapies in terms of failure rate (p=0.004;OR, 95%CI:0.74,0.60–0.90) and an advantage in terms of mortality (p=0.082;OR,95%CI:0.77,0.58–1.04).

Antipneumococcal cephalosporin monotherapy was associated with a low success rate (68.6%) and the highest mortality (16.2%); levofloxacin alone and combination of cephalosporin and macrolide resulted in higher success rates (79.1% and 76.7%, respectively) and in a significantly lower mortality (9.1% and 5.7%, respectively).

A low compliance with guidelines in the PP(44%) was obtained, indicating the need for future more aggressive and proactive approaches