Understanding variation in quality of antibiotic use for community-acquired pneumonia: effect of patient, professional and hospital factors

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Abstract
Objectives: To develop effective and targeted interventions to improve care for patients with community-acquired pneumonia (CAP), insight is needed into the factors that influence the quality of antibiotic use. Therefore, we measured the performance of nine quality indicators and studied determinants of variation in the quality of antibiotic use. Patients and methods: Data on 498 prospectively included patients with CAP from eight medium-sized Dutch hospitals were extracted from the medical charts. Outcomes of nine indicators were calculated using previously constructed algorithms. Multilevel logistic regression analysis was performed to explain differences in performance rates at the patient, doctor and hospital level. Results: Performance indicators were generally moderate. Markers of severe illness were found to be positive predictors of timely administration of antibiotics (low oxygen saturation on admission OR 1.11; 95% CI: 1.04–1.19) and obtaining blood samples for culture (low sodium concentration on admission OR 1.10; 95% CI: 1.03–1.16). Recent outpatient antibiotic therapy (OR 0.46; 95% CI: 0.26–0.80) and presence of a hospital antibiotic committee (OR 0.27; 95% CI: 0.08–0.90) were negatively associated with guideline-adherent empirical therapy. The main positive predictor of timely administration of antibiotics (within 4 h) was antibiotic administration in the Emergency Department (ED) (OR 3.9; 95% CI: 1.96–8.73). Conclusions: We gained new insights into factors that determine quality of antibiotic prescription in hospitals. Treatment in the ED, rather than in the ward, will result in earlier administration of antibiotics. Guidelines should clarify preferred antibiotic management of patients who have received antibiotics prior to admission. Hospital-based structures aimed at quality improvement, such as antibiotic committees, do not necessarily lead to better adherence to national standards. Efforts should be made to encourage these committees to implement national guidelines at a local level.