Local antibiotic guidelines for adult community-acquired pneumonia (CAP): a survey of UK hospital practice in 1999

Mark Woodheada,*, John Macfarlane and for the BTS CAP Guidelines Committeeb

a Department of Respiratory Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL; b Respiratory Infection Unit, City Hospital, Hucknall Road, Nottingham NG5 1PB, UK

Abstract

We investigated the guidelines in British hospitals for the management of adults admitted with community-acquired pneumonia (CAP). A questionnaire was sent to one consultant respiratory physician in each of the 263 hospitals in the British Thoracic Society (BTS) Directory of Training Posts and Services. Two hundred and thirteen (81%) responses were received: 178 (84%) had written CAP guidelines, of which 123 (69%) printed copies were received. For non-severe CAP a single antibiotic (74% of guidelines—most frequently amoxycillin or ampicillin) was the usual recommendation with the combination of a ß-lactam and a macrolide the second most frequent (24%). The latter combination was recommended for severe CAP in 81% of guidelines. Clostridium difficile-associated diarrhoea had influenced guideline recommendations, or was commented on as a concern, in 18% of responses. Written guidelines for antibiotic therapy in adults with CAP exist in most British hospitals and follow broadly the 1993 BTS guidelines, although combination therapy is used not infrequently for non-severe CAP.

Introduction

Since the publication of the British Thoracic Society (BTS) guidelines1 for the management of adults with CAP admitted to hospital, a number of changes have occurred. New pathogens have been described.2 Inappropriate antibiotic use and the spread of acquired bacterial antibiotic resistance has become a major concern. New macrolides and fluoroquinolones are now available. Concerns have been raised about the shortcomings of the 1993 guidelines.3,4

In order to inform the creation of new CAP guidelines we conducted a survey of the use and content of local antibiotic guidelines for CAP management in hospital and their relationship to the 1993 BTS guidelines.

Materials and methods

A questionnaire was sent to one respiratory physician at each of the 263 hospitals in the BTS Directory of Training Posts and Services.5 Information about, and a copy of, local written CAP guidelines were sought. A second mailing was sent to non-responders. Data were analysed using a spreadsheet (Microsoft Excel 97). Statistical analysis was by {chi}2 test with Yates' correction.

Results

There were 213 (81%) responses from hospitals where adults with CAP were admitted. One hundred and seventy-eight (84%) had written CAP guidelines, of which 123 (69%) printed copies were received.

Analysis of information regarding recommended antibiotics is restricted to printed guidelines seen by the authors.

Illness severity was one of the determinants of initial antibiotic choice in 102 (83%) hospitals. A single antibiotic was the usual (74%) recommendation for non-severe CAP. Amoxycillin (or ampicillin) alone was the most common first choice antibiotic (Table IGo), followed by the combination of a ß-lactam plus a macrolide. Erythromycin was specified in 22 (65%) and clarithromycin in 11 (32%) of the 34 recommendations that included a macrolide. Benzylpenicillin was recommended in 12, but quinolones in only three (two ciprofloxacin, one ofloxacin). Initial iv therapy was recommended for only 13 (11%) of those with non-severe illness; in all others oral or a choice of oral or parenteral therapy was specified.


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Table I. Antibiotic recommendations for non-severe community-acquired pneumonia
 
A combination of two (a ß-lactam plus a macrolide was most frequent) or three antibiotics was recommended for severe CAP in all but 3% of guidelines (Table IIGo). Macrolides, alone or in combination, were recommended in 93 hospitals (47 clarithromycin, 45 erythromycin, one not specified), cephalosporins in 66 (42 cefuroxime, 14 cefotaxime, nine ceftriaxone, one not specified), penicillins in 44 (22 ampicillin, 17 benzylpenicillin, five co-amoxiclav) and quinolones in eight (seven ciprofloxacin, one ofloxacin).


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Table II. Antibiotic recommendations for severe community-acquired pneumonia
 
Concerns about Clostridium difficile-associated diarrhoea (CDAD) were expressed in a total of 39 of the 213 (18%) questionnaire returns. A local high incidence of C. difficile influenced the guidelines in 21 hospitals. Nine of the 17 recommendations for benzylpenicillin occurred in these hospitals (P < 0.01) and six of the eight for quinolones (not significant).

Only 33 (27%) guidelines gave recommendations about how and when to switch from parenteral to oral therapy and only 26 (21%) indicated treatment duration.

Discussion

The excellent response rate and the inspection of printed guidelines in two-thirds of responses indicate that the findings are representative of CAP guidelines in most UK hospitals. However, the existence of separate guidelines within the same hospitals for other subgroups of patients with CAP cannot be excluded and the source of respondents may not cover specialist (e.g. geriatric) hospitals.

The BTS guidelines1 stratify empirical antibiotic recommendations into those for non-severe (or uncomplicated) and those for severe illness. This approach was followed in the majority of local guidelines.

The BTS empirical antibiotic recommendation for non-severe CAP is that oral treatment is usually adequate, and that an aminopenicillin or benzylpenicillin is a suitable choice. Local guidelines followed these recommendations in only two-thirds of cases, the major difference being the recommendation for dual therapy with a ß-lactam plus a macrolide in a quarter of hospitals. The perception that monotherapy with an aminopenicillin alone is too narrow-spectrum or a lack of consensus about what represents severe CAP are possible explanations for this.

The BTS recommendation for severe CAP is a combination of erythromycin with a second or third generation cephalosporin or, as an alternative, ampicillin plus flucloxacillin plus erythromycin, and 83% of local guidelines followed these recommendations. The most common deviation was the use of regimens containing benzylpenicillin plus a quinolone in 8% of cases, largely due to a high local incidence of CDAD.

Erythromycin is the macrolide specified in the 1993 BTS guidelines. The specified preference for clarithromycin in a significant number of recommendations indicates how much the perceived advantages of this macrolide have been translated into practice. Quinolone antibiotics usually only featured in local recommendations when CDAD was a problem. The newer fluoroquinolones were not included in any document.

In conclusion, written guidelines for antibiotic therapy in adults with CAP exist in most British hospitals and follow broadly the recommendations of the 1993 BTS guidelines, although combination therapy is used not infrequently for non-severe CAP. Concerns regarding CDAD had influenced recommendations in some hospitals. Audit of the content, use and impact of guidelines is essential and contributes to the revision of those guidelines.

Acknowledgments

Members of the BTS CAP Guidelines Committee include: Dr Tim Boswell, Consultant Microbiologist, City Hospital, Nottingham; Dr Graham Douglas, Consultant Physician, Aberdeen Royal Infirmary; Professor Roger Finch, Professor of Infectious Diseases, City Hospital, Nottingham; Dr Bill Holmes, Sherrington Park Medical Practice, Nottingham; Dr David Honeybourne, Consultant Physician, Birmingham Heartlands Hospital; Dr Wei Shen Lim, Specialist Registrar, City Hospital, Nottingham; Dr John Macfarlane, Consultant Physician, City Hospital, Nottingham (Chairman); Mr Richard Marriott, Senior Medical Librarian, City Hospital, Nottingham; Dr Peter Saul, Health Centre, Beech Ave, Wrexham; Dr Anne Thomson, Consultant Paediatrician, The John Radcliffe Hospital, Oxford; Dr Mark Woodhead, Consultant Physician, Manchester Royal Infirmary; Dr Jeremy Wyatt, Senior Fellow, School of Public Policy, University College, London.

Notes

* Corresponding author. Tel: +44-161-276-4381; Fax: +44-161-276-4989. Back

References

1 . British Thoracic Society. (1993). Guidelines for the management of community-acquired pneumonia in adults admitted to hospital. British Journal of Hospital Medicine 49, 346–50.[ISI][Medline]

2 . Steinhoff, D., Lode, H., Ruckdeschel, G., Heidrich, B., Rolfs, A., Fehrenbach, F. J. et al. (1996). Chlamydia pneumoniae as a cause of community-acquired pneumonia in hospitalised patients in Berlin. Clinical Infectious Diseases 22, 958–64.[ISI][Medline]

3 . Impallomeni, M., Galletly, N. P., Wort, S. J., Starr, J. M. & Rogers, T. R. (1995). Increased risk of diarrhoea caused by Clostridium difficile in elderly patients receiving cefotaxime. British Medical Journal 311, 1345–6.[Free Full Text]

4 . Smith, J. A., Redman, P. & Woodhead, M. A. (1999). Antibiotic use in patients admitted with acute exacerbations of chronic obstructive pulmonary disease. European Respiratory Journal 13, 835–8.[Abstract/Free Full Text]

5 . Hawkins, R. (1999). Directory of Training Posts and Services in Respiratory Medicine. Hawker Publications Ltd, London.

Received 1 October 1999; returned 5 January 2000; revised 3 February 2000; accepted 24 February 2000