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Guidelines for the Treatment of Community-acquired Pneumonia

Predictors of Adherence and Outcome

Servicio de Neumología, Hospital Universitario La Fe; Cuidados Intensivos, and Servicio de Neumología, Hospital Clínico, Valencia; Instituto de Neumología y Alergia, Hospital Clinic (Red Gira FIS-ISCIII-03/063); Servicio de Neumología, Hospital San Pablo, Barcelona; Servicio de Neumología, Hospital de Cruces, Bilbao; Servicio de Neumología, Hospital de la Princesa; Servicio de Neumología, Hospital 12 de Octubre, Madrid; Servicio de Neumología, Hospital Carlos Haya, Malaga; Servicio de Neumología, Hospital San Jorge, Huesca; Servicio de Neumología, Hospital Virgen de la Macarena, Sevilla; Servicio de Neumología, Hospital Germans Trias i Pujol, Badalona; Servicio de Neumología, Hospital Dr. Negrín, Las Palmas de Gran Canaria; Servicio de Neumología, Hospital General Universitario, Murcia; Servicio de Neumología, Hospital General, Guadalajara; and Servicio de Neumología, Hospital Ntra. Sra. de Covadonga, Oviedo, Spain

Correspondence and requests for reprints should be addressed to Rosario Menéndez, M.D., Servicio de Neumología, Hospital Universitario La Fe, Avda. de Campanar 21, 46009 Valencia, Spain. E-mail: rmenend{at}separ.es

Rationale: Some studies highlight the association of better clinical responses with adherence to guidelines for empiric treatment of community-acquired pneumonia (CAP), but little is known about factors that influence this adherence. Objectives: Our objectives were to identify factors influencing adherence to the guidelines for empiric treatment of CAP, and to evaluate the impact of adherence on outcome. Methods: We studied 1,288 patients with CAP admitted to 13 Spanish hospitals. Collected variables included the patients' clinical and demographic data, initial severity of the disease, antibiotic treatment, and specialty and training status of the prescribing physician. Measurements and Main Results: Adherence to guidelines was high (79.7%), with significant differences between hospitals (range, 47–97%) and physicians (pneumologists, 81%; pneumology residents, 84%; nonpneumology residents, 82%; other specialists, 67%). The independent factors related to higher adherence were hospital, physician characteristics, and initial high-risk class of Fine, whereas admission to intensive care unit decreased adherence. Seventy-four patients died (6.1%), and treatment failure was found in 175 patients (14.2%). After adjusting for Fine risk class, adherence to the guidelines was found protective for mortality (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.3–0.9) and for treatment failure (OR, 0.65; 95% CI, 0.5–0.9). Treatment prescribed by pneumologists and residents was associated with lower treatment failure (OR, 0.6; 95% CI, 0.4–0.9). Conclusions: Adherence to guidelines mainly depends on the hospital and the specialty and training status of prescribing physicians. Nonadherence was higher in nonpneumology specialists, and is an independent risk factor for treatment failure and mortality.

Key Words: antibiotic • compliance • mortality • pneumologist • resident

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