Empiric management of community-acquired pneumonia in Australian emergency departments

Objective: To describe empiric community-acquired pneumonia (CAP) management in Australian hospital emergency departments (EDs) and evaluate this against national guidelines, including use of the pneumonia severity index and antibiotic selection. Design: A multicentre, cross-sectional, retrospective audit, April 2003 to February 2005. Setting: 37 Australian hospitals: 22 principal referral hospitals, six large major city hospitals, four large regional hospitals, four medium hospitals and one private hospital. Participants: Adult patients with a diagnosis of CAP made in the ED. Data on 20 consecutive CAP ED presentations were collected in participating hospitals. Outcome measures: Documented use of the pneumonia severity index, initial antibiotic therapy prescribed in the ED, average length of stay, inpatient mortality, and concordance with national guidelines. Results: 691 CAP presentations were included. Pneumonia severity index use was documented in 5% of cases. Antibiotic therapy covering common bacterial causes of CAP was prescribed in 67% of presentations, although overall concordance with national guidelines was 18%. Antibiotic prescribing was discordant due to inadequate empiric antimicrobial cover, allergy status (including contraindication to penicillin), inappropriate route of administration and/or inappropriate antibiotic choice according to recommendations. There was no significant difference between concordant and discordant antibiotic prescribing episodes in average length of stay (5.0 v 5.7 days; P=0.22) or inpatient mortality (1.6% v 4.1%; chi(2) = 1.82; P=0.18). Conclusions: Antibiotic therapy for CAP prescribed in Australian EDs varied. Concordance with national CAP guidelines was generally low. Targeted interventions are required to improve concordance

Audit of Ticarcillan/Clavulanate Usage in a Large Teaching Hospital

Aim: To assess compliance with ticarcillin/clavulanate prescribing guidelines, appropriateness of prescribing and to identify any patterns of inappropriate use that may aid in improving prescribing. Method: Patients on ticarcillin/clavulanate were prospectively reviewed over an 8-week period. Data collected included: demographics, diagnosis, hospital or community-acquired infection, specific bacteriology, type of treatment, dose, dose quantity, appropriateness of treatment, and compliance with guidelines. Results: 100 patients on ticarcillin/clavulanate were reviewed and 65% were compliant with guidelines. Treatment was considered appropriate in 76% of patients. Non-compliant/inappropriate usage was most commonly observed in community-acquired pneumonia. Conclusion: This audit indicated widespread use of ticarcillin/clavulanate outside hospital prescribing guidelines, although in some cases, use was considered appropriate