Streamlining antibiotic use in community acquired pneumonia: A quality improvement initiative

BACKGROUND: Evidence suggests a 3-day total duration and early transition to oral therapy is safe in hospitalized patients with community acquired pneumonia (CAP)-though such care is not standard in the United States. To implement these evidence-based practices, a multidisciplinary group led by a hospitalist and antimicrobial stewardship updated an order set targeted at non-intensive care unit (ICU) patients with CAP. OBJECTIVE: Here, we assess the impact of our intervention on diagnostic and antibiotic treatment measures and associated clinical outcomes. METHODS: This is a retrospective, pre/post, observational quality improvement study of non-ICU inpatients with CAP admitted to a single academic medical center. The order set defaulted to 1 day of ceftriaxone without empiric atypical coverage for most patients, automatic de-escalation to oral amoxicillin on Day 2, a shortened total antibiotic duration of 3 days, and appropriate laboratory utilization. Primary outcomes were antibiotic duration and azithromycin use. Clinical outcomes were also assessed. RESULTS: The pre (1/2019-12/2021, n = 777) and post (1/2022-12/2023, n = 1416) intervention periods were compared using generalized linear models and interrupted time series adjusted for known confounders. After implementation of the orderset, total antibiotic duration (6-5 days, adjusted rate ratio: 0.92, 95% confidence interval [CI]: 0.89-0.95, p < 0.01) and azithromycin use (62.4% [485/777] to 39.4% [558/1416], adjusted odds ratio: 0.39, 95% CI: 0.33-0.47, p < 0.01) were significantly lower. Clinical outcomes were not significantly different postintervention. CONCLUSIONS: An order set backed by stewardship and hospitalists improves appropriate antibiotic use, showing that ongoing data-driven refinements can sustain stewardship and support the safety of shorter, narrower antibiotics for CAP in real-world care.