Background: Community acquired pneumonia (CAP) is commonly treated in hospitals and frequently results in antibiotic overuse. Important areas of overuse for CAP include excess treatment duration and unnecessary fluoroquinolone use. Smaller hospitals, including critical access hospitals (CAHs), often have limited resources for antibiotic stewardship compared to larger institutions which impedes stewardship efforts. After 2 years of programmatic success improving antimicrobial use for urinary tract infections (UTI) in CAHs, faculty from the University of Washington Center for Stewardship in Medicine (CSiM) and University of Utah worked with CAHs from the mountain west on an Intensive Quality Improvement Cohort (IQIC) focused on CAP.
Methods: From 10/2023 to 7/2024, 9 CAHs participated in an IQIC to assess and improve antibacterial treatment of CAP. Each CAH identified a stewardship champion who focused on understanding the baseline state, setting a QI goal, and engaging local stakeholders. Participation in IQIC included monthly online learning labs and quarterly individualized mentoring. In addition, each stewardship champion submitted deidentified clinical and treatment data via REDCap on a random sample of 3 CAP cases per month (goal total of 270 cases for all hospitals). Data submitted by the CAHs were collated for bimonthly performance feedback reports where the participating CAHs were benchmarked against their peers. Benchmarked data included antibiotic treatment duration (goal ≤ 6 days duration) and fluoroquinolone use (goal lower use). Barriers to data collection were discussed in small group sessions.
Results: A total of 178 cases were abstracted from the 9 hospitals. The median number of cases submitted per site was 17 (IQR 10,30) and 3 hospitals met their data abstraction goal (30 cases). Patient demographics, treatment setting and comorbidity information are listed in Table 1. Notably, most patients [73.6% (131/178)] had a CURB65 score of 0-1 which corresponds to outpatient level care and only 7.3% (13/178) of patients had a CURB65 score ≥ 3 which is considered for inpatient care. Antibiotic data are summarized in Table 1. Notably, the median total antibiotic duration was 8 days (IQR 6,10) with only 36% (64/178) of patients receiving an appropriately short (i.e., ≤ 6 days duration). Of the 14% (25/178) of patients who received a fluoroquinolone, only 28% (7/25) had a documented antibiotic allergy. CAHs with longer antibiotic durations also had a non-statistically significant trend towards higher fluoroquinolone use (Figure 1). Implementing an IQIC to steward CAP in CAHs presented multiple challenges. Identifying patients with a diagnosis of CAP via ICD-10 codes was difficult for CAHs who often lacked dedicated information technology support. Stewardship champions used variable ways to collect cases based on workflow and resources, including identifying patients by antibiotics prescribed. Chart identification of patients who presented to the ED and then were discharged were harder to capture compared to those admitted.
Conclusions: In participating CAHs, multiple barriers to measuring CAP-related antibiotic use existed. Despite patients admitted to CAHs having a low clinical acuity (CURB65 scores of 0-1), only a third had an appropriate antibiotic duration. Fluoroquinolone use was low overall, < 15%, but higher in hospitals with longer antibiotic durations. In summary, CAHs continue to require antibiotic stewardship efforts to improve antibiotic use in CAP.
