From the 2024 HVPA National Conference
Aaron Gandhi DO (Garden City Hospital), Raagini Yedidi MD, Apoorv Tiwari MD, MRCPUK, Hiba Asadulla, Undergraduate, Sujata Kambhatla MD, Amin Pasha MD
Background:
Withdrawing antibiotic treatment at the five-day mark in suitable inpatients with community-acquired pneumonia is recommended by the American Thoracic Society and the Infectious Disease Society of America.
Objective:
The goal of our intervention was to increase resident confidence and knowledge regarding algorithmic management of community-acquired pneumonia. Our longer-term goal is for our hospital to meet the state benchmark regarding adherence to optimal duration of therapy.
Methods:
A pre-intervention survey was conducted to assess Internal Medicine resident pre-intervention confidence and knowledge regarding management of community-acquired pneumonia (CAP). A laminated flowsheet of preferred antibiotic regimens for uncomplicated CAP was distributed in the Graduate Medical Education resident workspace. A one-hour lecture regarding management of community-acquired pneumonia was held for all Internal Medicine residents. Residents completed a post-intervention survey to determine whether confidence of uncomplicated CAP management had increased and whether resident knowledge of preferred regimen selection and duration of therapy had improved.
Results:
Twenty-four Internal Medicine residents were included for the intervention. Completion rate was 58.3% (14 residents) for the pre-intervention survey and 87.5% (21 residents) for the post-intervention survey. Residents rated their comfort level treating uncomplicated CAP from 1 to 5, 1 being uncomfortable and 5 being very comfortable. The average pre-intervention comfort level was 3.79, and the average post-intervention comfort level was 4.52 (p=0.0306). Before the intervention, 8 responses of 23 total (34.5%) were incorrectly selected pertaining to 7-day regimens and afterwards 5 of 37 total responses (13.5%) were incorrectly selected pertaining to 7-day regimens. Before the intervention, 84.62% (11) of respondents correctly identified ceftriaxone plus azithromycin/clarithromycin/doxycycline for 5 days and 23.08% (3) correctly identified ampicillin + sulbactam plus azithromycin/clarithromycin/doxycycline for 5 days of treatment as preferred regimens for uncomplicated CAP. Afterwards, 90.48% of respondents (19) correctly identified the first regimen and 47.62% of respondents (10) correctly identified the second.
Conclusions
Overall, the intervention appeared successful in increasing resident confidence in treating uncomplicated CAP. The intervention also decreased the incorrect response rate of 7-day regimens for the treatment of uncomplicated CAP, representing increased resident awareness of antibiotic withdrawal at the 5-day mark for uncomplicated CAP. The percentage of residents who successfully identified preferred regimens for uncomplicated CAP increased, but resident awareness of the ampicillin + sulbactam-based regimen was poorer, indicating a future area for growth. One strength of the intervention was that despite scheduling limitations precluding all residents from being able to attend the in-person lecture, circulation of the laminated flowsheets may have helped reach the majority of residents. Significance of the intervention may be under-represented due to selection bias as those who were uncomfortable with treatment of uncomplicated CAP may not have answered the pre-intervention survey, reflected by greater response rates to post-intervention survey. Additional future directions are to evaluate whether increased resident awareness actually improves hospital metrics tracking percentage of patients with uncomplicated CAP treated with 5 days of antibiotics. The longer term goal of meeting Michigan’s Hospital Medicines Safety benchmark will be assessed at the end of Q1 of 2024, and again on a quarterly basis.
Clinical Implications
This initiative will contribute to improved antibiotic stewardship and decreased cost for patients.