Chest

Chest

Volume 156, Issue 5, November 2019, Pages 843-851
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Original Research: Chest Infections
Antibiotic Use and Outcomes After Implementation of the Drug Resistance in Pneumonia Score in ED Patients With Community-Onset Pneumonia

A preliminary version of the data presented in this study was presented as a poster at the European Respiratory Society Congress, September 24, 2016, London, Great Britain (abstract No. PA607).
https://doi.org/10.1016/j.chest.2019.04.093Get rights and content

Background

To guide rational antibiotic selection in community-onset pneumonia, we previously derived and validated a novel prediction tool, the Drug-Resistance in Pneumonia (DRIP) score. In 2015, the DRIP score was integrated into an existing electronic pneumonia clinical decision support tool (ePNa).

Methods

We conducted a quasi-experimental, pre-post implementation study of ePNa with DRIP score (2015) vs ePNa with health-care-associated pneumonia (HCAP) logic (2012) in ED patients admitted with community-onset pneumonia to four US hospitals. Using generalized linear models, we used the difference-in-differences method to estimate the average treatment effect on the treated with respect to ePNa with DRIP score on broad-spectrum antibiotic use, mortality, hospital stay, and cost, adjusting for available patient-level confounders.

Results

We analyzed 2,169 adult admissions: 1,122 in 2012 and 1,047 in 2015. A drug-resistant pathogen was recovered in 3.2% of patients in 2012 and 2.8% in 2015; inadequate initial empirical antibiotics were prescribed in 1.1% and 0.5%, respectively (P = .12). A broad-spectrum antibiotic was administered in 40.1% of admissions in 2012 and 33.0% in 2015 (P < .001). Vancomycin days of therapy per 1,000 patient days in 2012 were 287.3 compared with 238.8 in 2015 (P < .001). In the primary analysis, the average treatment effect among patients using the DRIP score was a reduction in broad-spectrum antibiotic use (OR, 0.62; 95% CI, 0.39-0.98; P = .039). However, the average effects for ePNa with DRIP on mortality, length of stay, and cost were not statistically significant.

Conclusions

Electronic calculation of the DRIP score was more effective than HCAP criteria for guiding appropriate broad-spectrum antibiotic use in community-onset pneumonia.

Section snippets

Study Design

We conducted a quasi-experimental, pre-post implementation study of the impact of redeploying ePNa after changing from HCAP logic (2012) to the DRIP score (2015).

Population

Using a previously validated International Classification of Diseases, Ninth Revision code-based strategy, plus additional patients for whom treating physicians completed ePNa,11 we identified patients admitted to the hospital from the ED with community-onset pneumonia at four Salt Lake County Intermountain Healthcare hospitals during

Results

We observed 2,169 patients, 1,122 in ePNa with HCAP logic period (2012) and 1,047 in ePNa with DRIP score period (2015). Demographic data and clinical characteristics of the two periods are displayed in Table 2. The two cohorts had similar eCURB mean predicted 30-day mortality (5.9% vs 6.1%), vasopressor use (5.1% vs 6.6%), and mechanical ventilation (5.6% vs 7.4%), respectively. Fewer patients met HCAP criteria in 2012 (15.3%) than in 2015 (20.8%). Local influenza incidence was 4.16 per 10,000

Discussion

The DRIP score is a cumulative, probabilistic model for predicting risk of pneumonia because of drug-resistant pathogens based on well-established host risk factors. In an observational validation cohort of patients with a microbiologic etiology identified, we previously showed that DRIP score more effectively differentiated high and low probability of drug-resistant pathogens than HCAP criteria.17 In this prospective, electronic DRIP score implementation in a multicenter ED population, we now

Conclusions

Electronic implementation of DRIP score reduced initial empirical broad-spectrum antibiotic use without increasing inadequate empirical antibiotic therapy or mortality. When coupled with a MRSA nasal swab PCR-based strategy for de-escalation, reduction in overall vancomycin use was realized. Compared with HCAP criteria, the DRIP score is a more effective tool to assist clinicians in accurately identifying the risk of drug-resistant pathogens in pneumonia. Nevertheless, significant opportunities

Acknowledgments

Author contributions: B. J. W. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. B. J. W. and N. C. D. contributed to study concept and design. All authors contributed to acquisition, analysis, or interpretation of data. B. J. W. and N. C. D. contributed to drafting of the manuscript. All authors contributed to critical review of the manuscript for important intellectual content. J. S. and B. J. W.

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    FUNDING/SUPPORT: A portion of this study was funded by a grant from the Intermountain Research and Medical Foundation.

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    © 2019 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.