A total of 113 charts were reviewed from the list of poten­tial participants generated by the medical records department. Of the 113 patients, 58 met the inclusion criteria without any exclusion criteria. The other 55 charts were excluded for the following reasons: coding error or no clear diagnosis of pneumonia (n = 16), readmission (n = 9), onset of pneumonia more than 72 h after admission (n = 7), admission outside the defined study dates (n = 6), aspiration pneumonia (n = 4), concurrent HIV (n = 4), admission history incomplete (n = 3), residence in a nursing home (n = 3), active chemotherapy (n = 2), and concurrent tuberculosis (n = 1).

The preprinted order was used for 25 (43%) of the 58 patients admitted for community-acquired pneumonia (Table 1). Even when the preprinted order was used, the 3 sections of the form requiring physician input (antibiotic selection, assess­ment of pneumococcal vaccination status, and pneumonia severity index) were seldom completed correctly: for only 4 (16%) of these 25 patients were all 3 sections of the form completed appropriately, and for 1 patient (4%) errors or omissions meant that none of these sections was completed appropriately. Of the patients for whom the preprinted order was used, 9 (36%) had documentation of the assessment of pneumococcal vaccination status, and 13 (52%) had a record of the pneumonia severity index score. In contrast, of the patients for whom the preprinted order was not used, 3 (9%) had documentation of assessment of pneumococcal vaccination status, and none had a record of the pneumonia severity index score. Of the patients treated without use of the preprinted order, 21 (64%) received treatment in accordance with the IDSA-ATS guidelines. This proportion was significantly greater among the patients for whom the preprinted order was used (23 [92%] of 25 patients) (p = 0.012).
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Table 1. Characteristics of 58 Patients with Community-Acquired Pneumonia

Characteristic

Use of Preprinted Orders; No. (%) of Patients*


Yes(n = 25)


No(n = 33)


Sex (male)


14


(56)


13


(39)


Age, mean and range (years)


62


(36-91)


68


(23-85)


Allergy to penicillin


5


(20)


6


(18)


Comorbidities


Asthma


3


(12)


5


(15)


Chronic obstructive pulmonary disease


11


(44)


9


(27)


Smoker


12


(48)


7


(21)


Ex-smoker


4


(16)


11


(33)


Lung cancer


1


(4)


4


(12)


Other malignancy


1


(4)


1


(3)


Exacerbation of chronic heart failure


9


(36)


5


(15)


Previous use of antibiotic


B-Lactam


1


(4)


0


(0)


Other


4


(16)


5


(15)


*Except where indicated otherwise.

Among the patients treated with levofloxacin, this drug was prescribed inappropriately, as defined by the institution’s recommendations on the preprinted order, for 71% (10/14) of the patients for whom the preprinted order was not used and 50% (4/8) of those for whom the preprinted order was used (p = 0.32). More specifically, levofloxacin was given as monother­apy, as recommended by the preprinted order, to only 16 (72%) of the 22 patients who received this drug. Overall, criteria for the use of levofloxacin at the UHNBC were not met in 64% of cases (14/22).
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Table 2. Outcomes for 58 Patients with Community-Acquired Pneumonia

Type
of Therapy

Duration of

Duration of IV

Length of Stay,

Mortality Rate

CURB-65,

Antibiotic Use,

Therapy, Mean and

Mean
and

(No.
and %)

Mean
and Range

Mean
(days)

Range (days)

Range (days)

Preprinted order used (n

= 25)


5.9


3.2 (0-6)


6.3 (1-17)


0


1.8 (1-5)

Preprinted order not used
(n

= 33)


5.5


4.0 (0-12)


5.9 (1-12)


5 (15)


2.2 (0-5)

Levofloxacin monotherapy
(n


= 16)


4.6



1.7

(0-6)


4.9 (3-11)


0


2.4 (1-4)

IV(n= 8)


4.3


3.4 (2-6)


5.0 (3-11)


0


2.4 (1-4)

PO(n= 8)


4.9


NA


4.9 (3-9)


0


2.5 (1-4)

B-Lactam + macrolide(n= 27)


5.3


4.2 (1-8)


5.5 (1-16)


2 (7)



1.9

(0-4)

Any other combination(n= 15)


7.3


4.9 (0-12)


7.6 (2-17)


3 (20)


2.0 (0-5)

The duration of antibiotic therapy, length of stay, mortality rate, and standardized severity-of-illness scores (i.e., CURB-65 severity score) are outlined in Table 2. There were no statisti- cally significant differences in length of stay among the regimens. Five deaths occurred among patients for whom the preprinted order was not used. Two of these deaths were due to respiratory failure associated with comorbid metastatic lung cancer. The 3 remaining deaths were due to severe sepsis (cultures positive for Streptococcus pneumoniae in 2 cases and for Haemophilus influenzae in the third case). All of these organ­isms were susceptible to the initial empiric therapy (cephalosporin and a macrolide).  generic cialis 20mg