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Pneumonia Observational Incidence and Treatment: A Multidisciplinary Process Improvement Study

By Jan Broek, MD, Ellen McDonald, RN, France Clarke, RRT, Carolyn Gosse, BSc(Pharm), Roman Jaeschke, MD, MSc and Deborah Cook, MD, MSc.

Jan Broek is an internist with the Jagiellonian University School of Medicine and Polish Institute for Evidence Based Medicine, Krakow, Poland. Ellen McDonald and France Clarke are ICU research coordinators, Carolyn Gosse is an ICU pharmacist, Roman Jaeschke is an intensivist, and Deborah Cook is an intensivist and Academic Chair of Critical Care Medicine at St Joseph’s Healthcare and McMaster University, Hamilton, Ontario, Canada.

Corresponding author: Deborah J. Cook, McMaster Health Sciences Center, Room 2C10, Departments of Clinical Epidemiology and Biostatistics and Medicine, 1200 Main St W, Hamilton, Ontario, Canada L8N 4A6 (e-mail: debcook{at}mcmaster.ca).

Background Little information is available on the types, causes, and treatment of pneumonia in intensive care unit patients in usual clinical practice.

Objective To characterize treatment of patients with presumed pneumonia in a tertiary care intensive care unit and to identify potential areas for improvement in care.

Methods In a prospective, cohort study, the sample consisted of all consecutive patients treated in an intensive care unit during a 3-month period. For patients with presumed pneumonia, data were collected on incidence of pneumonia, diagnostic investigations, microbial isolates, and antibiotics prescribed.

Results Of 194 admissions, 73 patients were treated for pneumonia: 47 had community-acquired pneumonia; 12 had hospital-acquired pneumonia; 12 had ventilator-associated pneumonia, both early (7) and late (5); and 2 had intensive care unit–acquired pneumonia. Approximately 71% of patients had microbiological tests performed. Among 54 microbial isolates, 51.9% were gram-positive bacteria, 31.5% were gram-negative bacteria, and 9.3% were Candida species. The most commonly used antimicrobials were quinolones (54 of 192 prescriptions) and cephalosporins (33); each patient received a median of 3 antibiotics.

Conclusions Most cases of pneumonia were community acquired. The most common causative organisms were gram-positive cocci. Four quality improvement strategies were rationalization of antibiotic use during rounds, nurses’ reporting of culture results, review of antibiotic appropriateness by a pharmacist, and redesign of the clinical information system.