Guideline Adherence in Community-Acquired Pneumonia: Do Doctors Follow the Rules and Does It Matter?

Daniel Sion, Sharon Berkley, Limor Adler, Shiraz Vered, Maayan Bracha

Keywords: Community-Acquired Pneumonia (CAP), Guideline Adherence, Antibiotic Therapy, Clinical Outcomes, Hospitalization Rates

Background:

Community-acquired pneumonia (CAP) is a common illness influenced by pathogen type, patient demographics, and geography. The 2019 ATS/IDSA guidelines recommend empirical antibiotics based on patient history and risk factors.

Research questions:

This study examines adherence to CAP treatment guidelines and its impact on clinical outcomes.

Method:

A retrospective cohort analysis of adults diagnosed with CAP (2019–2020) via chest x-ray, using Maccabi Health Group data in Israel. Patients were categorized as healthy or non-healthy, and adherence was assessed against guidelines. Outcomes were defined as treatment success or failure, with failure including antibiotic switching or hospitalization. Analyses compared outcomes by antibiotic type, adherence, and patient characteristics.

Results:

Of 3,014 patients, 54% received non-guideline-concordant treatment. Guideline adherence significantly reduced hospitalization rates in older, medically complex patients (OR 0.27–0.71). In other groups, adherence did not significantly affect hospitalization rates, which were low (3%). Notably, 60% of patients on non-adherent treatments were prescribed antibiotics suited for different clinical profiles. Healthy patients (ages 18–39, 40–65) on non-guideline treatments had fewer antibiotic switches (OR 2.79 [1.79–4.33], 3.12 [2.14–4.54]).

Conclusions:

Physicians frequently deviate from CAP guidelines, often prescribing broad-spectrum antibiotics without improving outcomes like hospitalization rates. Non-adherence was linked to worse outcomes in older, medically complex patients. Reduced antibiotic switching in healthy patients on non-adherent treatments may reflect the broad-spectrum nature of these antibiotics but requires further study. Current evidence underscores the need to improve guideline adherence to optimize CAP management and address barriers to compliance.

Points for discussion:

How can outpatient guideline adherence be improved?

What drives antibiotic switching decisions?

What research is needed to compare first-line treatments?

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